Chest Pain

Approach to Chest Pain - Nick King

Typical Chest Pain / Angina

  • Substernal Chest pain which is provoked by exertion/stress, relieved by rest or nitro
    • Typical = 3/3
    • Atypical = 2/3
    • Non-cardiac = 0/3
  • Be cautious in women and diabetics who may have atypical presentations of ACS


Diagnoses Not to Miss “The Serious Six”

  • Acute Coronary Syndrome
  • Aortic Dissection/Aneurysm
  • Pulmonary Embolus
  • Pneumothorax
  • Cardiac Tamponade
  • Mediastinitis (e.g, Esophageal Perforation or Rupture - Boerhaave’s Syndrome)


Other Differential Diagnoses

  • Skin: Laceration, Herpes Zoster
  • Subcutaneous: Cellulitis, Abscess 
  • Musculoskeletal: Costochondritis, fracture, myositis, sprain/strain
  • Pleural space (no pain receptors in the lung): PNA, tumor, pleuritis
  • Pericardium: Pericarditis
  • Heart: Myocarditis, spontaneous coronary artery dissection (SCAD), coronary vasospasm, aortic stenosis, stress-induced cardiomyopathy (Takotsubo), decompensated heart failure
  • Esophagus: GERD, Esophagitis
  • Trachea: Tracheitis, Tracheal Tear


Physical Exam

  • Vitals: BP in both arms (do while interviewing - quick, easy, inexpensive)
  • Hemodynamic profile (warm/dry, warm/wet, cold/dry, cold/wet)
  • Palpate chest: evaluate costochondral junction, subcutaneous emphysema, examine skin
  • Cardiac: murmurs, rub for pericarditis, JVD for heart failure or PE with RV strain
  • Pulm: absent breath sounds for PTX, crackles for left heart failure, PNA
  • Abdomen: abdominal pain mistaken or referred as chest pain
  • Extremities: asymmetric leg swelling (>2 cm difference) for DVT/PE


Diagnostic Studies

  • EKG –ACS (STEMI, new LBBB, NSTEMI, Wellen’s sign), pericarditis, pericardial effusion
  • Troponin – ACS, PE (w/ R heart strain), myocarditis
  • CXR – PTX, PNA, dissection, esophageal rupture
  • Bedside Ultrasound – pericardial effusion, R heart strain for PE, wall motion abnormality for infarct/ischemia or stress-induced CM, valvular disease, lung sliding/PTX
  • CT-A – gold standard for PE (consider V/Q if unable to obtain and otherwise healthy lungs); Dissection can be diagnosed w/ CT-A, MR-A, or TEE
  • Additional Labs: CBC/BNP/lactate/ABG or VBG


Evaluation for Coronary disease






EKG Stress

Intermediate or low risk Screening with high NPV

Functional status w/ Bruce treadmill protocol

Exercise tolerance

limits use


Cannot have LBBB

Nondiagnostic if 85% target HR not achieved

Echo Stress

More sensitive than EKG

Detects prior infarcts

(fixed WMAs)

Evaluates hemodynamics

Dobutamine contraindicated

in active ACS, arrhythmias, LVOT obstruct, HTN, AS

Can be useful to eval low grade low flow AS


Hold BB

SPECT stress

Better PPV than Echo

Assess viability

Adenosine or Regadenason contraindicated in reactive airway disease

No caffeine or theophylline prior

PET stress

Better PPV than Echo

Assess viability

Better for pts with larger abdominal girth, less diaphragmatic attenuation


Cardiac MRI


Assesses viability

Can assess nonischemic vs ischemic cardiomyopathy; HR must be < 70

Coronary CT

Very high NPV for stenosis that can be done in ED

Contrast media reactions

CIN lower risk than cath

Might have poor lumen if heavy calcium burden

HR < 70

Coronary Angiogram

Diagnostic and Therapeutic


High Cardiac Risk STEMI

ACS + cardiogenic shock

or new HF


High risk NSTEMI:

Refractory angina, new arrhythmia

troponin on medical mgmt

Direct visualization of lumen

Therapeutic PCI

CIN with contrast

Cath site complications

Rare: SCAD, cholesterol emboli

First line evaluation of stable in angina with pts w/HF or new HF

Positive test often

Radial access preferred


Case request cath lab


NPO MN prior

Groin  check if femoral access


Additional Information

  • VA-specific point: a pt with chest pain + positive troponin is admitted to the CCU, so make sure to talk to the ED Attending/NOD prior to admitting a pt like this to the floor