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Chest pain Last updated: November 17, 2020

Summary
Nontraumatic chest pain is one of the most common causes of emergency department visits
and is common in both inpatients and outpatients. The differential diagnosis is broad and
includes cardiac (e.g., acute coronary syndrome, pericarditis), gastrointestinal (e.g., GERD,
gastritis, PUD), musculoskeletal (e.g., costochondritis), and psychiatric (e.g.,
generalized anxiety disorder, panic attack) etiologies. Any life-threatening causes of chest pain,
such as acute coronary syndrome and pulmonary embolism, should be immediately evaluated
and assessed. Once life-threatening causes have been ruled out (either by patient history,
examination, or rapid diagnostics), a more thorough history and examination should be
performed to narrow the differential diagnosis and guide further diagnostic workup and
therapy. Traumatic causes of chest pain are not addressed here.

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Management REGISTER / LOG IN

Approach [1]

1. ABCDE survey

2. Obtain 12-lead ECG: If ECG shows STEMI, see “Treatment” in acute coronary syndrome.
3. Establish IV access.

4. Continuous telemetry and pulse oximetry

5. Initiate supplemental O2 if there is evidence of hypoxemia.

6. Perform a focused history and physical examination.

7. Perform targeted diagnostics (see “Diagnostics” below) and further tests as required.

8. Treat the underlying cause.

Red ags for chest pain

Sudden onset

Exertional chest pain

Substernal or left-sided pain

Radiation to the left arm, jaw, and/or back

Associated shortness of breath

Quality of chest pain: crushing, pressure (e.g., “an elephant sitting on my chest”), tearing, or
ripping
New murmur

Diaphoresis, nausea, or vomiting

Chest wall crepitus

Distant heart sounds

Difference > 20 mm Hg in systolic blood pressure between arms [2]

Pulsus paradoxus

Hypotension
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Hypoxia
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Immediately life-threatening causes

Acute coronary syndrome (STEMI, NSTEMI, unstable angina)

Pulmonary embolism

Aortic dissection
Tension pneumothorax

Cardiac tamponade

Esophageal rupture

Diagnostics
The diagnostic workup should be guided by the pretest probability of the diagnoses under
consideration. The following list includes some commonly used diagnostic tools that can be
helpful in diagnosing or ruling out possible etiologies in patients with undifferentiated chest
pain.

Laboratory studies

[3]
Troponin
D-dimer

CBC

ESR/CRP

BMP
LFTs

Lipase, amylase
BNP

Type and screen

Coagulation studies (e.g., INR, PTT)

Lactate

Cultures (e.g., blood cultures, sputum cultures)

Procalcitonin
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Toxicology screen
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Respiratory virus panel

Hepatitis panel

Imaging

12-lead ECG

X-ray of the chest

FAST bedside ultrasound

X-ray of the abdomen (upright)

X-ray of the ribs

CT chest with contrast

CT pulmonary angiogram

CT abdomen and pelvis with IV contrast

Right upper quadrant ultrasound

TTE and/or TEE

Lung ultrasound

V/Q scan

Duplex of the extremity

Cardiovascular causes

Characteristic clinical Diagnostic ndings Acute

features management

Heavy, dull, ECG: ST-segment See the acute

STEMI [4]
pressure/squeezing elevation/depression, management
sensation T-wave inversions, Q waves checklist for
STEMI.
Substernal pain
with radiation to ↑ Troponin
left shoulder TTE: hypokinesis, regional
Nausea, vomiting wall motion abnormalities
Diaphoresis,
anxiety

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Dizziness,
Characteristic clinical Diagnostic ndings Acute
lightheadedness, REGISTER / LOG IN
features
syncope management

Pain may improve

ECG: nonspeci c changes, See the acute
NSTEMI/UA [5] with nitroglycerin.
including T-wave inversions, management
ST-segment depressions checklist for
NSTEMI/UA.
Increased or normal
troponin
TTE: Regional wall motion
abnormalities may be
present.

Aortic Sudden onset of Elevated D-dimer See the acute

severe, sharp management
dissection ECG: nonspeci c ST-
tearing chest or checklist for
[6][7][8] segment changes
abdominal pain that aortic
radiates to the back CXR: widening of the aorta dissection.

Hypotension, CT angiography of
syncope, chest/abdomen/pelvis:
neurological intimal ap with false lumen
symptoms
Asymmetrical blood TEE:
pressure, pulse proximal aortic dissection,
de cit tamponade,
aortic regurgitation
New diastolic
murmur
Symptoms of
myocardial ischemia

Cardiac Tachypnea, dyspnea ECG: low voltage, See the acute

electrical alternans management
tamponade Tachycardia
checklist for
[9] Pulsus paradoxus CXR: enlarged
cardiac
cardiac silhouette
Cardiogenic shock tamponade.
TTE: circumferential uid
Beck triad: layer, collapsible chambers
hypotension, , high EF, dilated IVC
elevated JVD, Inspiration: Both
muf ed ventricular and atrial
heart sounds septa move sharply to the
left.
Expiration: Both
ventricular and atrial
septa move sharply to the
right.

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Characteristic clinical Diagnostic ndings Acute

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features management

Pericarditis [10]
Sharp, pleuritic, ↑ ESR, ↑ CRP, leukocytosis See the acute
retrosternal chest management
[11]
pain
↑ Troponin [10]
checklist for
ECG: diffuse, ST-segment acute
Exacerbated by
elevations without pericarditis.
lying down;
reciprocal ST-segment
improved by leaning
depression, PR-segment
forward
depression, or T-wave
Not relieved with inversions
nitrates
CXR: normal
High-pitched
TTE: Pericardial effusion
pericardial friction
may be present.
rub

Heart failure Chest pressure Clinical diagnosis See the acute

management
exacerbation Cough, dyspnea Labs: ↑ BNP, ↑ troponin,
checklist for
[12][13][14][15] Hypoxemia hyponatremia
heart failure
CXR: diffuse opacities, exacerbation.
Crackles, JVD,
Kerley B lines
peripheral edema
TTE: global or focal wall
abnormalities, systolic
and/or diastolic dysfunction,
decreased LVEF

Takotsubo History of a recent ↑ Troponin, ↑ BNP See the acute

stressful event management
cardiomyopathy ECG: ST-segment elevations,
checklist for
[16][17] Retrosternal chest T-wave inversions
Takotsubo
pain, dyspnea, TTE: decreased LVEF, cardiomyopathy.
heavy, dull, regional wall motion
pressure/squeezing abnormalities , apical
sensation ballooning
Hypotension, shock
cMRI: myocardial edema,
regional wall motion
Most common in abnormalities
elderly women
Coronary angiography: no
acute coronary stenosis or
occlusion

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Gastrointestinal causes REGISTER / LOG IN

Noncardiac chest pain is most commonly due to gastrointestinal and

musculoskeletal disorders. [18]

Characteristic clinical Diagnostic ndings Acute management

features

Esophageal Retrosternal chest CXR, upright AXR: See the acute

pain, neck pain, mediastinal air and/or management
perforation
epigastric pain with subdiaphragmatic air, checklist for
[19][20]
radiation to the back pleural effusion, esophageal
pneumothorax perforation.
Dyspnea, tachypnea, Lateral neck x-ray:
tachycardia subcutaneous emphysema
Dysphagia Contrast esophagography
(gold standard): contrast leak
Signs of sepsis
[21]
Mackler triad (chest
pain, vomiting, CT chest (with oral contrast)
subcutaneous : extraluminal air,
emphysema esophageal thickening
)
Mediastinal crepitus
History of recent
endoscopy or severe
emesis (
Boerhaave syndrome)

GERD and Postprandial Clinical diagnosis See “Management

substernal chest pain, of GERD”.
erosive De nitive diagnosis requires
pressure, burning,
esophagitis EGD and/or
re ux symptoms
24-hour esophageal pH
[22][23]
Aggravated by lying in monitoring
the supine position
and certain foods (e.g.,
coffee, spices)
Epigastric tenderness

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Characteristic clinical Diagnostic ndings Acute management

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features

Peptic ulcer Epigastric pain Anemia, positive FOBT (in See the acute
cases of bleeding ulcer) management
disease Duodenal ulcer: pain
checklist for PUD.
[24][25][26] relieved with food; Urea breath test for H. pylori:
weight gain positive in most cases of PUD
Gastric ulcer: pain
exacerbated by food; EGD: mucosal erosions
weight loss and/or ulcers
Signs of GI bleed
History of NSAID
intake

Acute Severe epigastric pain ↑ Lipase, amylase See the acute

that radiates to the management
pancreatitis Abdominal ultrasound:
back checklist for
[27][28][29] pancreatic edema,
acute
Nausea, vomiting peripancreatic uid,
pancreatitis.
Epigastric tenderness, gallstones
guarding, rigidity Abdominal CT with IV
contrast : pancreatic
Upper abdominal pain
edema, peripancreatic fat
Hypoactive bowel stranding, gallstones
sounds
History of gallstones
or alcohol use

Mallory- Epigastric pain that CBC: anemia See the acute

radiates to the back management
Weiss EGD: longitudinal mucosal
checklist for
syndrome Repeated episodes of tears, typically at the
Mallory-Weiss
severe vomiting gastroesophageal junction
[30][31] syndrome.
Hematemesis
Melena, dizziness,
syncope

Pulmonary causes

Characteristic clinical Diagnostic ndings Acute management

features

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Characteristic clinical Diagnostic ndings Acute management

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features

Pulmonary Pleuritic chest pain Elevated D-dimer See the acute

management
embolism Acute onset dyspnea, ↑ Troponin, BNP
checklist for
[32] hypoxemia ECG: normal sinus rhythm pulmonary
Cough, hemoptysis (most common), embolism.
sinus tachycardia, signs of
Unilateral leg
right ventricular strain
swelling or history of
DVT CTA chest:
pulmonary artery lling
Hypotension, shock
defect
(if massive PE)
V/Q scan: perfusion-
ventilation mismatch
TTE: right ventricle
hypokinesis with normal
apical movement
Wells criteria for
pulmonary embolism

Tension Severe, sharp chest Clinical diagnosis See the acute

pain management
pneumothorax CXR: absent lung markings,
checklist for
[33][34] Dyspnea, hypoxemia tracheal deviation,
tension
History of trauma pneumomediastinum
pneumothorax.
Hyperresonance,
decreased breath
sounds,
tracheal deviation
Tachycardia,
hypotension

Pneumonia Fever, chills Labs: leukocytosis, ↑ ESR/ See the acute

CRP, ↑ procalcitonin management
[35] Cough, dyspnea
checklist for
Hypoxemia Positive sputum culture
pneumonia.
CXR: consolidation,
Crackles, egophony
pleural effusion
CT chest with IV contrast:
hyperdense consolidation

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Characteristic clinical Diagnostic ndings Acute management

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features

Spontaneous Sudden, sharp CXR (in inspiration): See the acute

unilateral chest pain increased lucency, displaced management
pneumothorax
lung markings, checklist for
[33][36][37]
subcutaneous emphysema spontaneous
Acute dyspnea
pneumothorax.
Hypoxemia Ultrasound: absent
lung sliding
Hyperresonance,
decreased breath
sounds on affected
side
Crepitus
History of lung
disease or trauma

Asthma Dyspnea, cough ABG: ↓ pH, ↑ PaCO2, ↓ See the acute

PaO2 (respiratory acidosis) management
exacerbation Tachycardia
checklist for
[38] Tachypnea, Peak expiratory ow:
asthma
hypoxemia decreased from predicted
exacerbation.
or personal best
Diffuse wheezing,
decreased or absent
breath sounds
Increased work of
breathing

COPD Dyspnea, cough ABG: ↓ pH, ↑ PaCO2, ↓ See the acute

PaO2 (respiratory acidosis) management
exacerbation Purulent sputum
checklist for
[39][40] Tachypnea, ↑ CRP,↑ Procalcitonin (if
COPD
hypoxemia underlying bacterial
exacerbation.
infection)
Diffuse wheezing,
CXR: hyperin ated lungs;
decreased breath
signs of pneumonia,
sounds
pneumothorax, and/or
Increased work of pleural effusion may be
breathing present
Signs of imminent Check for severe
respiratory arrest: vitamin D de ciency (< 10
confusion, absent ng/ml I )
breath sounds,
bradycardia

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Characteristic clinical Diagnostic ndings Acute management

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features

Pleural Unilateral, CXR: homogeneous opacity See the acute

pleuritic chest pain with blunting of the management
effusion
costophrenic angle checklist for
[41][42] Dyspnea
pleural effusion.
Dry, nonproductive Ultrasound: hypoechoic
cough space between the parietal
and visceral pleura
Dullness to
percussion,
decreased breath
sounds, decreased
tactile fremitus
Pleural friction rub

Other causes

Costochondritis [43]

Clinical features

Sharp, well-localized pain that is reproducible on palpation of costal cartilage

History of recent exercise/exertion/chest wall trauma

Diagnostics:
[43]
Clinical diagnosis

CXR: normal

Treatment:
Pain management

Acetaminophen

NSAIDs (e.g., naproxen , ibuprofen )

Supportive care: reduction of activities that provoke symptoms, cough suppressants, heat
or ice packs

Acute herpes zoster [44][45]

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Clinical features REGISTER / LOG IN

Severe burning or throbbing pain

Thoracic dermatomes most commonly affected

Maculopapular rash that develops into a vesicular rash in a dermatomal distribution

Immunocompromised status
Diagnostics:

Clinical diagnosis
[45]
PCR of vesicle uid positive for varicella-zoster virus DNA

Treatment:
Antivirals (See the acute management checklist for herpes zoster.)

Panic disorder [46]

Clinical features:

Chest tightness, palpitations, tachycardia

Tachypnea

Diaphoresis, dizziness
Paresthesias

Anxious appearance
Recent stressful exposure

Diagnostics: Clinical diagnosis

Treatment:

Breathing exercises
Consider benzodiazepines for an acute episode (e.g., lorazepam , diazepam ).
[46][47]
Assess for suicidal ideation.
Psychiatry consult and/or referral for cognitive behavioral therapy

Functional chest pain [22][48]

Clinical features:

Retrosternal chest pain or discomfort

No associated esophageal symptoms (e.g., no heartburn, dysphagia)
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Diagnostics:
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Diagnosis of exclusion
Rome IV criteria for functional chest pain

Treatment:
Reassure the patient.
[48]
Referral to psychologist
Consider initiating medical therapy with one of the following:

TCA (e.g., amitriptyline )

SARI (e.g., trazodone )
SSRI (e.g., sertraline )

SNRI (e.g., venlafaxine )

Differential diagnoses
Cardiac
Acute coronary syndrome

Cardiac tamponade
Pericarditis

Myocarditis
Endocarditis

Takotsubo cardiomyopathy
Aortic dissection

Valvular disease (e.g., aortic stenosis, mitral regurgitation, aortic regurgitation)

Stable angina

Vasospastic angina
Hypertensive crisis

Heart failure exacerbation

Postcardiac injury syndrome

Postmyocardial infarction syndrome

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Postpericardiotomy syndrome
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Pulmonary
Pulmonary embolism

Tension pneumothorax
Pneumothorax
Pneumonia

Bronchitis
Asthma exacerbation

COPD exacerbation
Hemothorax

Pulmonary edema
Pleural effusion

Pleuritis
Fibrinous pleuritis

Rheumatoid pleuritis
Lupus pleuritis

Pulmonary sarcoidosis
Lung contusion

Pulmonary infarct
Lung abscess
Lung cancer

Musculoskeletal
Costochondritis

Chest trauma
Chest wall pain

Rib fracture
Rib contusion

Osteoarthritis of the sternoclavicular or manubriosternal joint

Osteoarthritis of the shoulder joints

Fibromyalgia

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Slipping rib syndrome

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Tietze syndrome

Overuse myalgia
Thoracic outlet syndrome

Gastrointestinal
Esophageal perforation

Boerhaave syndrome
Mallory Weiss syndrome

Gastroesophageal re ux disease
Acute erosive gastritis

Acute erosive esophagitis

Eosinophilic esophagitis

Dyspepsia
Peptic ulcer disease

Esophageal motility disorder

Achalasia
Distal esophageal spasm

Hypercontractile esophagus
Esophageal hypersensitivity

Sliding hiatal hernia

Biliary colic

Cholelithiasis
Choledocholithiasis

Cholecystitis
Acute pancreatitis

Acute hepatitis
Liver abscess

Fitz-Hugh-Curtis syndrome
Renal
Renal infarct

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Renal capsular hematoma

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Dermatological

Acute Herpes zoster

Postherpetic neuralgia

Hematologic/Oncologic
Acute pain crisis

Acute chest syndrome

Malignancy

Malignant pleural effusion

Splenic infarct

Rheumatologic
Rheumatoid arthritis
SLE

Fibromyalgia
Functional chest pain

Psychiatric
Generalized anxiety disorder

Panic disorder
Major depressive disorder

Somatic symptom disorder

Substance use disorders (e.g., cocaine, methamphetamines, alcohol)

Illness anxiety disorder

See also differential diagnosis of increased troponin and differential diagnosis of ST-elevations
on ECG.
The differential diagnoses listed here are not exhaustive.

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