Evaluation of Chest Pain

Flowchart

First Pass

Chest pain is a triage symptom before it becomes a diagnosis

Identify unstable or time-sensitive causes first: ACS, aortic syndromes, PE, tension pneumothorax, tamponade, and esophageal rupture when context suggests it.

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Immediate stabilization

Act first on life-threatening physiology

Shock, severe hypoxemia, syncope, tearing pain, persistent ischemic symptoms, or rapidly worsening respiratory compromise should move ahead of routine risk stratification.

Cardiac / ischemic

Pressure / exertional

ACS or ischemic chest pain

Pressure-like, exertional, radiating pain with dyspnea, nausea, or diaphoresis should keep ischemia high on the list.

Positional / pleuritic

Pericarditis or pericardial process

Positional or pleuritic pain may still be cardiac, especially with diffuse ECG changes or viral context.

Vascular catastrophe

Tearing + abrupt

Aortic dissection or acute aortic syndrome

Abrupt severe pain, pulse deficits, neurologic symptoms, or syncope should raise concern quickly.

Pleuritic + dyspnea

Pulmonary embolism

Acute pleuritic pain, dyspnea, tachycardia, or DVT risk factors support PE reasoning.

Pulmonary / pleural

Sudden unilateral

Pneumothorax

Sudden pleuritic pain with dyspnea or unilateral findings should redirect attention here.

Fever + cough

Pneumonia or pleuritic respiratory infection

Infectious pulmonary causes can present primarily as chest pain with dyspnea.

Lower-risk and noncardiac mimics

Reproducible

Chest-wall or musculoskeletal pain

Reproducibility lowers concern for ACS, but does not absolutely exclude it in the wrong context.

Burning / post-prandial

GI or esophageal chest pain

Reflux and esophageal sources can mimic ischemic symptoms, especially when the story is less exertional.

Evaluation of Chest Pain

Interactive diagnostic assistant

Likely diagnoses from entered data

Recommended next labs, imaging, and diagnostics

Flowchart