Chest pain is one of the most serious and time-sensitive symptoms seen in emergency and primary care settings. It ranges from benign musculoskeletal pain to life-threatening causes such as myocardial infarction (MI), aortic dissection, pulmonary embolism, and pneumothorax.
Your uploaded chart organizes chest pain based on:
- First priority: EKG
- STEMI vs. non-STEMI
- Emergent causes
- Non-emergent causes
- Red flags and workup
- Treatment guidelines
This article translates the chart into a clear, academic, exam-friendly guide.
First Step: ALWAYS Get an EKG
The chart emphasizes:
“#1 EKG”
An EKG should be performed immediately on all patients with chest pain to rule out:
- STEMI
- Arrhythmias
- Pericarditis
- Ischemia changes
Early EKG comparison is helpful—serial EKGs are essential if symptoms persist.
Pathway 1: STEMI (ST-Elevation Myocardial Infarction)
A STEMI is a true emergency requiring immediate intervention.
Management Steps
- Activate the MI team
- IV access, oxygen if needed, monitor
- Aspirin + nitroglycerin (if not inferior MI)
- Antiplatelet therapy
- Heparin
- Labs: BMP, CBC, LFTs, coags, cardiac enzymes, BNP
- Cath lab activation within 90 minutes
- Obtain consent or prepare for transfer
Pathway 2: No STEMI → Evaluate Other Life-Threatening Causes
If EKG is not showing STEMI, the clinician must evaluate for other emergencies.
Ask key questions:
A. Aortic Dissection?
Clues:
- Sudden tearing pain radiating to the back
- Hypertension
- Neurological deficits
- Pulse difference between arms
Workup:
CXR or CT-ATreatment:
- Lower heart rate (goal HR 60–70)
- Maintain MAP 60–75
- Consult cardiothoracic surgery
- Avoid ASA until dissection is excluded
B. Pneumothorax (PTX)?
Clues:
- Tall, thin body habitus
- Trauma
- Tobacco use
- Sharp, sudden chest pain
- Absent breath sounds
Workup:
CXR or ultrasoundTreatment:
- Needle/pigtail decompression
- Chest tube
C. Pulmonary Embolism (PE)?
See Shortness of Breath chart for full details.
Clues:
- Pleuritic chest pain
- DVT symptoms
- Recent surgery or immobilization
- OCP use
- Tobacco
- Cancer
- Sudden SOB
Workup:
- PERC
- D-dimer
- CT-angiogram
Treatment:
- Anticoagulation
- tPA if unstable (massive PE)
Low Bar for ACS/NSTEMI
Even with a non-STEMI EKG,
you must keep a very low threshold for ACS/NSTEMI workup
if the symptoms suggest ischemia.
Emergent Chest Pain Causes
Your chart lists the highest-risk conditions:
| Disease | Key Clues | Workup | Treatment |
|---|---|---|---|
| ACS/NSTEMI | Pressure, exertional pain, SOB, diaphoresis | Serial EKGs, enzymes | ASA, NTG, heparin; admit |
| Aortic dissection | Tearing pain → back, HTN | CT-A | BP/HR control; surgery |
| Esophageal rupture | Vomiting + chest pain (Boerhaave), EtOH | CXR/abdominal XR | Surgery |
| PE | Pleuritic CP, DVT signs | D-dimer/CT-A | Anticoagulation |
| Pneumothorax | Sharp pain in tall/tobacco/trauma | CXR/US | Chest tube |
| Tamponade | Beck's triad: hypotension, muffled heart sounds, JVD | Echo | Pericardiocentesis |
| Cocaine CP | ACS symptoms | EKG, troponins | No β-blockers; benzos, nitrates |
| Endocarditis | Fever, murmur, IVDU, Janeway/Osler | Echo, blood cultures | Antibiotics + cardiology |
Likely Non-Emergent Causes
| Condition | Key Clues | Workup | Treatment |
|---|---|---|---|
| GERD | Burning, post-prandial → throat | Clinical | GI cocktail, PPIs |
| Musculoskeletal pain | Reproducible with palpation | Exclusion | NSAIDs |
| Pericarditis | Pain worse lying flat, better sitting up | EKG, echo | NSAIDs |
| Pneumonia | Fever, cough, sputum | CXR | Antibiotics |
HEART Score (For ACS Risk Stratification)
The chart references the HEART score, used to determine risk of major cardiac events.
HEART =
- History
- EKG
- Age
- Risk factors
- Troponin
Scores guide:
- Discharge
- Observation
- Admission
High-Yield Pearls & Pitfalls
- ACS and PE patients may appear stable initially—do NOT rely on appearance.
- Always get old EKGs for comparison.
- Diaphoresis, vomiting, and radiation to the right arm are classic ACS signs.
- Symptom improvement after GI cocktail does NOT rule out cardiac causes.
- Pain patients may misinterpret chest wall pain for cardiac issues—always check EKG.
- Unilateral leg swelling → suspect DVT → risk of PE.
Documentation Essentials
Document in detail:
General
- Diaphoresis
- Present chest pain characteristics
- Tachypnea
- BP in both arms
Extremities
- Leg edema (unilateral/bilateral)
- DVT signs
Heart/Chest
- Rate and rhythm
- Murmurs/rubs
- Chest wall tenderness
Lungs
- Breath sounds
- Wheezing
- Rhonchi
- Rales
Overall Impression
- Sick vs. stable
- Likely emergent vs. benign pathology
Accurate documentation supports safe disposition and medicolegal protection.
Quick Summary Algorithm (Simplified)
1. EKG first2. STEMI? → Activate MI team
3. No STEMI → Evaluate for:
- Dissection
- PTX
- PE
FAQs About Chest Pain
1. What chest pain requires immediate action?
Tearing pain with neurological signs, severe SOB, hypotension, or STEMI indicators.
2. Does burning chest pain always mean GERD?
No—ischemia may feel like “burning.”
3. Why avoid β-blockers in cocaine chest pain?
They cause unopposed α-adrenergic vasoconstriction → worsen vasospasm.
4. When should CT-A be done?
If suspicion exists for pulmonary embolism or aortic dissection.
5. Can pneumonia cause chest pain?
Yes, especially pleuritic pain.
6. What is the most dangerous missed diagnosis?
Aortic dissection or STEMI.
