APPROACH TO CHEST PAIN

Typical ischemic pain

• Central / retrosternal

• Pressure, squeezing, gripping, heaviness, tightness

• Exertional / stress-related

• May radiate to left/right/both arms, jaw, neck, shoulders, epigastrium

• Usually relieved by rest / nitroglycerin

Angina equivalents

• Dyspnea, nausea — especially in females, elderly and DM.

• Avoid the term “atypical” → use cardiac / possible cardiac / noncardiac.

Duration

• Stable angina: usually 2–10 min

• Unstable angina: usually <20 min, crescendo pattern / reduced exercise tolerance

• MI: usually ≥20 min, often with dyspnea, weakness, nausea/vomiting.

Think noncardiac when pain is:

• Pleuritic → worse with breathing/cough

• Positional

• Sharp

• Fleeting → seconds

• Localized to one fingertip

• Reproduced by palpation/movement

• Mainly middle/lower abdomen

• Constant for many hours

• Radiates to lower extremities

Important caution

• ⚠️ These features reduce probability but do not independently rule out ACS

Aortic dissection

• Sudden + excruciating + ripping/tearing

• Ascending → anterior/midline chest

• Descending → posterior chest/back

• Risk factors: Marfan, Ehlers-Danlos, bicuspid AV, pregnancy, hypertension.

Pulmonary embolism

• Sudden dyspnea + pleuritic chest pain

• Massive PE → severe persistent substernal pain

• Pulmonary infarction → lateral pleuritic pain

• Significant PE → hypotension + syncope + RV failure.

Pericarditis

• Sharp + pleuritic + positional

• Worse with: breathing, coughing, position, swallowing

• Infectious → often pleuritic

• Uremic/noninfectious → little or no pain

• Referred to shoulder/neck via phrenic nerve C3–C5

• Lateral diaphragmatic involvement → upper abdomen/back

• May mimic MI, pancreatitis or cholecystitis.

Pulmonary

• Tracheobronchitis → burning midline pain

• Pneumonia → localized + pleuritic pain

• Pneumothorax → sudden pain + dyspnea

• Tension pneumothorax → life-threatening

• Asthma → chest tightness

• Pulmonary hypertension → angina-like pain from RV hypertrophy/right-heart ischemia.

GI

• GERD: burning; worse recumbent; improves upright/acid therapy

• Esophageal spasm: squeezing → may mimic angina

• Mallory-Weiss: prolonged vomiting

• Boerhaave: severe vomiting → esophageal rupture + mediastinitis

• PUD: 60–90 min after meals; usually epigastric

• Cholecystitis: RUQ ± chest/back

• Pancreatitis: intense epigastric → back.

Musculoskeletal / other

• Costochondritis

• Cervical disc disease

• Herpes zoster

• Heavy exercise

• Pain reproduced by pressure/movement

• Panic syndrome → tightness + breathlessness + anxiety, generally ≥30 min.

OPQRST

• O → Onset: sudden/gradual

• P → Provoking/relieving: exertion, rest, nitroglycerin

• Q → Quality: pressure, burning, heaviness

• R → Region/radiation: jaw, arms

• S → Severity

• T → Timing/duration

Also ask

• Pulmonary + GI symptoms.

• ⚠️ Pain severity does NOT reliably predict ischemia.

• ⚠️ Nitroglycerin response does NOT reliably distinguish cardiac from noncardiac pain.

Major risk factors

• Hypercholesterolemia

• HTN

• DM

• Smoking

• Family history of premature CAD

• Advanced age

• Male sex

Additional points

• Previous MI → established CAD + higher ACS/multivessel risk

• Young patients → ask about recent cocaine use

• History alone cannot rule in or rule out ACS.

• Best diagnostic accuracy: History + Examination + ECG + Biomarkers

Important findings

• ST elevation → STEMI

• ST depression ≥0.5 mm → ischemia

• T-wave inversion ≥2 mm → ischemia, less specific

• Posterior/LCX ischemia may be missed → consider posterior leads

• Persistent symptoms → serial ECG + biomarkers

Patterns

• Pericarditis: diffuse ST ↑ + PR ↓

• PE: RAD + RBBB + T inversion V1–V4 ± S1Q3T3

• ⚠️ Normal ECG does NOT rule out ACS; NPV ~80–90%.

Preferred

• cTnI / cTnT

• CK-MB → less sensitive → not recommended.

MI diagnosis

• Rise/fall of cTn + clinical evidence of ischemia

• ⚠️ Troponin elevation ≠ automatically MI.

Troponin can rise with

• Acute HF

• PE

• Hypertensive emergency

• Acute renal failure

• Sepsis/critical illness

• Stroke

• Extreme exertion

• Myocarditis

• Stress cardiomyopathy

• Arrhythmia

• Aortic syndrome

• Cardiac procedures

• Severe valvular disease

• CKD, chronic HF, LVH, stable CAD, etc.

hs-cTn

• Earlier detection + serial delta change

• Validated strategies: 0 h / 0–1 h / 0–2 h / 0–3 h

• → Very low hs-cTn or no significant rise can rule out MI in appropriate patients.

• Validated strategies can achieve NPV ≥99%.

• If hs-cTn unavailable → conventional cTn at presentation + 3–6 h.

HEART SCORE

• H = History

• E = ECG

• A = Age

• R = Risk factors

• T = Troponin

HEART SCORE

RISK

WHAT TO DO

0–3

LOW

Consider early discharge if serial troponin negative/no concerning features

4–6

INTERMEDIATE

Further evaluation/testing

7–10

HIGH

Manage as high-risk ACS

Repeat / reassess

• Repeat hs-cTn at 3–6 h + reassess HEART/EDACS

↓ Lower risk

• No/minimal troponin increase

• HEART ≤3 / EDACS <16

• No high-risk features

• → Consider discharge ± outpatient testing

↓ Still intermediate

• No significant troponin increase

• But doesn’t meet low-risk criteria

• → Noninvasive testing

↓ Higher risk

• Significant troponin rise

• Ongoing/recurrent ischemic pain

• New ischemic ECG changes

• → UA/NSTEMI / higher-risk ACS pathway.

CCTA = ANATOMY

• Best favored by:

• No known CAD / low likelihood

• No severe coronary calcium

• Prior normal/mildly abnormal/inconclusive stress test

• No contrast allergy/significant renal dysfunction

• Stress testing unavailable/poor quality

• Need coronary/noncoronary anatomy

Stress testing = FUNCTION

• Favored by:

• Known CAD / higher risk

• Severe coronary calcification

• Inconclusive prior CCTA

• Contrast allergy

• Significant renal dysfunction

• Poor/unavailable CCTA

• Need scar/microvascular assessment → PET/CMR