Chest pain is a common but potentially life-threatening symptom that can originate from a wide array of pathologies affecting thoracic or abdominal structures. It is a cardinal sign of numerous acute cardiovascular, respiratory, gastrointestinal, musculoskeletal, psychological, and hematological disorders. Prompt and systematic assessment is essential, as the underlying etiology can range from benign to fatal.

Clinical presentation of chest pain

• Onset: Sudden or gradual

• Character: Sharp, stabbing, dull, squeezing, burning, or pressure-like

• Location: Central (retrosternal), left-sided, right-sided, diffuse, or localized

• Radiation: Neck, jaw, back, shoulders, arms (particularly left arm)

• Duration: Seconds to hours

• Aggravating/Relieving Factors: Exertion, stress, respiration, posture, meals, medications

• Associated Symptoms: Dyspnea, nausea, vomiting, diaphoresis, palpitations, syncope, anxiety

Emergency interventions

When a patient presents with chest pain, immediate triage is necessary to identify red flags:

• Vital Signs: Assess for hypotension, hypertension, tachypnea, tachycardia, oxygen desaturation, or paradoxical pulse.

• High-Risk Indicators: Sudden severe pain, hemodynamic instability, altered mental status, new-onset arrhythmias, signs of cardiac ischemia, or respiratory distress

• Immediate Actions:

  • Administer oxygen if hypoxic

  • Establish IV access

  • Place the patient on cardiac monitor

  • Obtain a 12-lead ECG within 10 minutes of arrival

  • Prepare for advanced cardiac life support (ACLS) protocols if needed

History and Physical Examination

History:

Determine precise onset, progression, quality, and pattern

Ask about personal and family history of cardiac, pulmonary, or GI disease

Review current medications and any recent changes

Investigate lifestyle factors: smoking, alcohol, illicit drug use (e.g., cocaine)

Physical Examination:

Inspection: Observe for cyanosis, respiratory effort, and asymmetrical chest movement

Palpation: Assess for chest wall tenderness, thrills, heaves, and tactile fremitus

Percussion: Look for dullness suggesting effusion or hyperresonance suggesting pneumothorax

Auscultation: Listen for heart murmurs, gallops, rubs, and abnormal breath sounds (e.g., wheezes, crackles)

Peripheral Signs: Jugular venous distention (JVD), peripheral edema, capillary refill, extremity pulses

Differential Diagnosis of Chest Pain (Medical Causes)

A. Cardiovascular Causes

• Angina Pectoris:

  • Exertional, retrosternal pain relieved by rest or nitroglycerin

  • Radiates to jaw, neck, or left arm

  • Associated with nausea, diaphoresis, and palpitations

• Myocardial Infarction (MI):

  • Prolonged (>20 minutes), crushing chest pain unrelieved by rest

  • ECG changes (ST elevation, T wave inversion, Q waves)

  • Elevated cardiac enzymes (troponin, CK-MB)

• Aortic Dissection:

  • Sudden tearing pain radiating to the back

  • Blood pressure discrepancy between arms

  • Widened mediastinum on chest X-ray

• Mitral Valve Prolapse:

  • Atypical chest pain, mid-systolic click on auscultation

  • May have palpitations and fatigue

B. Respiratory Causes

• Pulmonary Embolism (PE):

  • Pleuritic pain, dyspnea, tachypnea

  • Hemoptysis, syncope, or hypotension in massive PE

  • Confirmed by D-dimer, CT pulmonary angiogram

• Pneumothorax:

  • Sudden unilateral chest pain with dyspnea

  • Absent breath sounds and hyperresonance on affected side

• Pneumonia/Pleuritis:

  • Fever, productive cough, localized pain worsened by breathing

  • Crackles, egophony, dullness to percussion

C. Gastrointestinal Causes

• Gastroesophageal Reflux Disease (GERD):

  • Burning retrosternal pain, postprandial or nocturnal

  • Responds to antacids, worsened by lying down

• Esophageal Spasm or Rupture:

  • Severe retrosternal pain mimicking MI

  • May occur after vomiting (Boerhaave’s syndrome)

• Cholecystitis:

  • Right upper quadrant pain radiating to right shoulder

  • Positive Murphy’s sign, fever, vomiting

• Pancreatitis:

  • Epigastric pain radiating to the back

  • Associated with alcohol use or gallstones

D. Musculoskeletal causes

• Costochondritis:

  • Localized, reproducible pain on palpation

  • No systemic symptoms

• Rib Fracture or Trauma:

  • History of injury, localized tenderness

E. Psychiatric causes

• Panic Disorder/Anxiety:

  • Sharp, brief chest pain with hyperventilation

  • Palpitations, fear of dying, dizziness

F. Hematologic/Infectious Causes:

• Sickle Cell Crisis:

  • Chest syndrome due to infarction

  • Fever, hypoxia, cough, pain

• Anthrax (Inhalation):

  • Initial flu-like symptoms followed by mediastinitis

  • Rapid progression to dyspnea, hypotension, and death

Table: Causes of Chest Pain – Clinical Summary for Health Professionals

Diagnostic workup

• Electrocardiogram (ECG): First-line test for ischemia/infarction

• Cardiac Enzymes: Troponin I/T, CK-MB

• Chest X-Ray: Evaluate for pneumothorax, effusion, cardiomegaly

• Echocardiography: Rule out wall motion abnormalities, tamponade, valvular lesions

• CT Angiography: Suspected PE or aortic dissection

• Laboratory Tests: CBC, D-dimer, renal function, LFTs, ABGs

Management Principles

• STEMI: Immediate reperfusion with PCI or thrombolytics

• NSTEMI/Unstable Angina: Antiplatelets, anticoagulants, nitrates, beta-blockers, risk stratification

• PE: Anticoagulation, thrombolysis for massive PE

• Pneumothorax: Needle decompression or chest tube insertion

• GERD: PPIs, lifestyle modifications

• Anxiety: Reassurance, benzodiazepines, psychological evaluation

Conclusion

Chest pain requires a structured and evidence-based approach. Accurate diagnosis relies on a detailed history, thorough physical exam, and timely use of diagnostic tools. Understanding the wide differential and recognizing life-threatening conditions promptly can significantly reduce morbidity and mortality.

Appendices:

• A. Chest Pain Algorithm for Emergency Triage

• B. Comparison Table: Cardiac vs Non-cardiac Chest Pain

• C. Clinical Pearls for History Taking in Chest Pain