DrZep

Cardiology

Acute chest pain

Undifferentiated chest pain in an adult presenting to acute care

Time-critical presentation5-stage reasoningCase walk-through

What to ask

Separate the four killers — ACS, dissection, pulmonary embolism, oesophageal rupture — from everything else in the first three minutes.
  • Onset: instantaneous and maximal at once suggests dissection or embolism; crescendo over minutes suggests ischaemia.
  • Character and radiation: pressure to jaw or arm (ischaemia), tearing to the back (dissection), sharp and pleuritic (pericardium, pleura, embolism).
  • Duration and pattern: seconds is rarely cardiac; hours of unremitting pain with distress is high risk.
  • Exertional relationship and what relieves it — rest, nitrate, antacid, position.
  • Risk factors: age, smoking, diabetes, hypertension, lipids, family history, cocaine, recent immobility or surgery, connective tissue disease.
  • Current antiplatelet, anticoagulant and previous revascularisation.

Discriminators

  • Pain reproducible with a single finger and unchanged over days is unlikely to be ACS.
  • Syncope with chest pain moves dissection and massive embolism up the list.
  • Relief with a nitrate is not diagnostic — oesophageal spasm responds too.

Case walk-through — Crushing chest pain at 06:40

4 decisions · moderate

Case vignette

A 58-year-old man with hypertension and a 30-pack-year smoking history arrives 90 minutes after sudden crushing central chest pain radiating to the jaw. He is sweaty, blood pressure 138/84 mmHg, pulse 92/min, SpO2 97% on air.

  1. 1

    What is your first action?

  2. 2

    The ECG shows 3 mm ST elevation in II, III and aVF with reciprocal depression in I and aVL. What is the territory and next step?

    Answer the previous step to continue.

  3. 3

    He becomes hypotensive at 82/54 mmHg with clear lung fields and raised JVP after sublingual nitrate. What now?

    Answer the previous step to continue.

  4. 4

    He undergoes successful PCI. Which discharge package is correct?

    Answer the previous step to continue.

Full checklist

Original structured checklist
  1. 1

    History

    • Onset, character, radiation, duration, exertional relationship, response to nitrates
    • Associated features: sweating, nausea, dyspnoea, syncope, palpitations
    • Risk factors: age, smoking, diabetes, hypertension, lipids, family history, cocaine use
    • Previous cardiac disease, procedures, and current antiplatelet or anticoagulant therapy
  2. 2

    Examination

    • Vital signs in both arms; oxygen saturation; peripheral perfusion
    • Heart sounds, murmurs, rubs, JVP and signs of congestion
    • Chest examination for consolidation, effusion or pneumothorax
    • Legs for DVT; chest wall for reproducible tenderness (not exclusionary)
  3. 3

    Initial tests

    • 12-lead ECG within 10 minutes of arrival, repeated if pain recurs
    • High-sensitivity troponin at presentation and per the local rule-in/rule-out pathway
    • Chest radiograph, FBC, urea and electrolytes, glucose, lipids
    • Bedside echocardiography if unstable or a mechanical complication is suspected
  4. 4

    Risk stratification

    • Apply the HEART score to select early discharge versus admission in undifferentiated pain
    • Apply GRACE in confirmed NSTEMI to decide invasive timing
    • Use Wells and PERC when pulmonary embolism is a realistic consideration
  5. 5

    Differential

    • Cardiac: ACS, myocarditis, pericarditis, aortic dissection, arrhythmia
    • Respiratory: pulmonary embolism, pneumonia, pneumothorax, pleurisy
    • Gastrointestinal: reflux, oesophageal spasm, rupture, pancreatitis, biliary colic
    • Musculoskeletal and psychological: costochondritis, rib injury, panic disorder
  6. 6

    Immediate treatment

    • STEMI: aspirin plus a P2Y12 inhibitor, anticoagulation, and primary PCI within 120 minutes or thrombolysis if not achievable
    • NSTEMI: antiplatelets, anticoagulation and invasive assessment timed by risk
    • Oxygen only if SpO2 < 90%; analgesia and nitrates unless hypotensive or with inferior infarction and RV involvement
    • Treat the non-cardiac cause identified
  7. 7

    Follow-up

    • Secondary prevention: high-intensity statin, dual antiplatelet duration, ACE inhibitor, beta-blocker
    • Cardiac rehabilitation referral and lifestyle counselling
    • Safety-netting advice with a documented plan if pain recurs

Related diseases

acute coronary syndromecommunity acquired pneumoniaheart failure

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