Chest pain in the intensive care unit (ICU) is a common and potentially serious complaint. The differential diagnosis of chest pain is broad, and the physician must not be limited to cardiac etiologies, although myocardial infarction and angina must always be considered. The initial approach to chest pain requires a rapid evaluation, history, physical, electrocardiogram, chest radiograph, and the consideration of additional laboratory and radiologic tests.

The initial approach should be to ensure that the patient has hemodynamic and respiratory stability. This usually results from an assessment of the patient’s vital signs and clinical condition. The patient who is bradycardic and hypotensive requires more urgent diagnosis than the patient in pain who is awake and conversant. If the condition is stable, a concise history regarding the nature of the pain should be obtained. A mnemonic that may be helpful in asking the necessary questions is OLDCAAR (Table 316.1). Classic symptoms of myocardial infarction or ischemia include chest pain that may be characterized as sharp, dull, pressure, tearing, or crushing or a feeling of doom. Patients may complain of radiation to the chin, left arm, or back. Associated symptoms may include nausea, vomiting, diaphoresis, and palpitations. The astute clinician should consider atypical symptoms such as “gas” or heartburn to be cardiac in etiology until proven otherwise.

A focused physical exam should be performed looking first for cardiovascular problems such as a difference in the pulses between the limbs, pulses paradoxus, pulse volume and rate, new murmurs, rubs, or gallops. It is important to note that the exam may be normal despite a cardiac etiology. Additional physical signs may provide insight to other etiologies. For example, rhonchi or rales, absent breath sounds, or hyper-resonance may point toward a pulmonary etiology, whereas abdominal tenderness, masses, absent or abnormal abdominal sounds, guarding. and rebound may provide insight into an abdominal component.