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  Chest pain is a very common complaint in emergency department patients.

  
  
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  A rapid electrocardiogram and chest x-ray will help distinguish between multiple emergent causes of chest pain.

  
  
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  The exclusion of life-threatening sources of chest pain should be the emergency physician’s chief diagnostic concern.

Chest pain is one of the most common presenting complaints in the emergency department (ED). As several fatal conditions present with chest pain, it is imperative to rapidly and thoroughly evaluate these patients to distinguish between emergent and nonemergent causes. Approach chest pain with a broad differential diagnosis and utilize your history, physical exam, and ancillary testing to narrow down the etiology.

The pathophysiology of chest pain will vary tremendously depending on the specific etiology. Regardless of the source, pain sensation ultimately occurs owing to stimulation of either visceral or somatic nerve fibers. Somatic nerve fibers innervate the skin and parietal pleura. Patients will typically complain of a pain that is sharp in nature and easily localized. Potential etiologies include pulmonary embolism, pneumothorax, musculoskeletal injury, herpes zoster infection, pneumonia, and pleurisy. Conversely, visceral nerve pain is often vague in quality, poorly localized, and will frequently radiate to nearby structures. Patients may deny the actual sensation of “pain” and rather describe their condition as a heaviness, pressure, or simple discomfort. Potential etiologies include acute coronary syndrome (ACS), aortic dissection, gastroesophageal reflux, and pericarditis.

History

A detailed history is essential when evaluating patients with chest pain, as no single element in isolation is sensitive or specific enough to determine either the etiology or the severity of the complaint. Ascertain the character of the pain to help determine a somatic or visceral source. For example, a sharp and stabbing pain is less likely in patients with ACS, but rather common in patients with pulmonary embolism. Identify the exact location of the pain and whether there is any associated radiation. Prototypical ischemic chest pain presents either just beneath the sternum or on the left side and radiates to either the left arm or jaw, whereas a mid-thoracic “tearing type” pain radiating straight through to the back is classically associated with aortic dissection. Determine the severity and duration of the pain. A mild, sharp pain lasting only seconds in duration is rarely associated with a serious pathology, whereas pain lasting greater than 10 minutes may suggest a more serious etiology. Recurrent pain that lasts for many hours or days per episode is unlikely to be cardiac.

In patients with a known history of heart disease, ascertain whether or not their symptoms mirror prior presentations. Patients with pain that is either similar to or more severe than a previous myocardial infarction (MI) have a markedly increased likelihood of ACS. Identify exacerbating or relieving factors, as this can quickly impact management. Patients with potential cardiac presentations frequently complain of pain that is worse with exertion and improved with rest. Pain that is worse with cough or deep inspiration (pleuritic pain) is typically associated with either pleurisy, a musculoskeletal etiology, or pulmonary embolism. Epigastric pain that is worse with meals usually signifies a gastrointestinal etiology. Pain that is aggravated by emotional stress may point to an underlying psychiatric etiology. Finally, inquire about any associated symptoms. For example, nausea and diaphoresis have been associated with a higher likelihood for ACS.

Unfortunately, the long-term risk factors for underlying heart disease (high cholesterol, smoking, hypertension, diabetes, family history) have not been shown to help in the differentiation of acute chest pain patients in the ED. Nonetheless, this history should be taken. A history of an underlying hypercoagulable state (eg, pregnancy, malignancy) should alert you to a possible pulmonary embolism (PE), whereas a history of an underlying connective tissue disorder (eg, Marfan syndrome) should prompt an evaluation for aortic dissection. Ask about any illicit drug habits, as cocaine use has been associated with accelerated atherosclerosis, acute MI, and aortic dissection.

Physical Examination

Note the general appearance of the patient. Those with ACS or other serious etiologies may be clutching their chest and frequently appear anxious, pale, and diaphoretic. This “sick vs not sick” mentality will guide the rapidity of your examination. As with all emergency patients, assess the vital signs and ensure adequate airway, breathing, and circulation (ABCs). Note abnormal vital signs to help guide your differential diagnosis. A detailed examination of the heart, lungs, abdomen, extremities, and neurologic systems will ensure that no emergent causes of chest pain are overlooked. Listed next are some emergent presentations matched with potential physical exam findings.