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Chest Pain

Rule out the six killers first — then risk-stratify the rest.

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobRule out the six killers first — then risk-stratify the rest.

  1. ECG within 10 minutes; repeat if symptoms evolve or the first tracing is nondiagnostic.
  2. Exclude the six killers: ACS/OMI, dissection, PE, tension pneumothorax, Boerhaave, tamponade.
  3. Run an assay-specific hs-cTn 0/1h or 0/2h pathway (HEART/EDACS if using contemporary troponin).
  4. Use a validated assay-specific pathway; a merely normal troponin is not the same as a very-low single-sample rule-out threshold.

Chest pain is ~5–10% of ED visits.

The task is not to name every cause but to exclude the life-threats, then risk-stratify the rest. A nonischemic ECG and a troponin within its reference range do not alone exclude ACS. Selected patients qualify for a single very-low hs-cTn rule-out only within a validated pathway and with symptom onset at least 3 hours earlier. With high-sensitivity assays, an assay-specific 0/1-hour or 0/2-hour algorithm (ESC) is the spine of the pathway; HEART/EDACS remain useful adjuncts, especially with contemporary (non-hs) troponin.

Acute Coronary Syndrome (STEMI / NSTEMI / UA / OMI) Critical

Key: Serial ECG + hs-troponin algorithm — not a single snapshot. Occlusion MI can exist without classic STE.

Aortic dissection Critical

Key: Tearing pain to the back, pulse/BP differential, wide mediastinum. Anticoagulating this as ACS can be lethal.

Pulmonary embolism Critical

Key: Very-low gestalt → PERC; otherwise a validated Wells/age-adjusted or YEARS probability-adapted D-dimer pathway. Normal sats do not exclude it.

Tension pneumothorax Critical

Key: A clinical diagnosis — hypotension + unilateral absent breath sounds = decompress, don’t image first.

Esophageal rupture (Boerhaave) Critical

Key: Post-emesis chest pain, subcutaneous emphysema, mediastinal air on CT.

Cardiac tamponade Critical

Key: Beck triad is late; pulsus paradoxus and electrical alternans — bedside echo is the test.

Myocarditis / Takotsubo / cocaine ischemia Emergent

Key: Young patients with atypical pain, HF features, or sympathomimetic use.

GERD / musculoskeletal / anxiety Common

Key: Real diagnoses — only after life-threats and validated ACS/PE pathways are negative.

Tick what your patient has — the banner updates as you go.

OPQRST + radiation to jaw, arm, or back

High-risk ACS features

exertional, rest pain, diaphoresis, syncope

Tearing/inter-scapular migration → dissection; pleuritic → PE/pleural; post-emesis → Boerhaave

Risk enhancers

age, diabetes, smoking, family history, cocaine, CKD

VTE risks

immobility, malignancy, surgery, estrogen, pregnancy

Vitals with bilateral BP; pulse oximetry

Cardiac

new murmur (AS/dissection), rub (pericarditis/tamponade)

Lungs

symmetry, crackles (HF), unilateral absent sounds (PTX)

Vascular

pulse deficits; pulsatile abdominal mass (AAA)

Chest-wall reproducibility lowers — but does not exclude — ACS

Immediate (minutes)

  • 12-lead ECG within 10 minutes; repeat at 15–30 min if symptoms evolve or the first tracing is nondiagnostic
  • Posterior (V7–V9) and right-sided leads when inferior or isolated anterior ST depression
  • POCUS: pericardial effusion, lung sliding, RV strain

Labs

  • hs-Troponin 0/1h (preferred) or 0/2h assay-specific ESC/ACC-AHA algorithm — not a legacy 6-hour wait when an hs-cTn CDP is in use; with conventional troponin, use the validated serial timing and risk score in the local pathway
  • HEART or EDACS as adjuncts — essential if using contemporary (non-hs) troponin
  • D-dimer only when PE pretest is not high (PERC if very-low gestalt; a validated age-adjusted or YEARS cutoff; do not combine thresholds ad hoc)
  • CBC, BMP, coagulation if antiplatelet/anticoagulation planned

Imaging

  • CXR: mediastinum, PTX, edema, free air
  • CTA chest for dissection or PE; echo for RWMA/tamponade
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • hs-cTn rule-out (0/1h or 0/2h) + non-ischemic ECG + no high-risk features; or HEART 0–3 with serial negative troponin on a score-based pathway. Arrange follow-up ± outpatient CTA/stress per local CDP.

Admit (observation / telemetry)

  • Observe-zone troponin kinetics, HEART 4–6, new AF, ongoing atypical symptoms, or incomplete rule-out.

ICU / cath lab activation

  • STEMI or occlusion-MI pattern, hemodynamic instability, suspected dissection/tamponade, refractory ischemic symptoms, arrhythmia.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Chest Pain:
    • Hypotension, syncope or pre-syncope
    • ST elevation, hyperacute T waves, De Winter, Wellens, or posterior STE (isolated ST depression V1–V3)
    • Sgarbossa / Smith-modified criteria in LBBB or paced rhythm
    • Pain radiating to the back with pulse/BP asymmetry
    • New murmur or pulsus paradoxus
    • Unilateral absent breath sounds or tracheal deviation
    • Subcutaneous emphysema after vomiting
    • Ongoing pain despite antianginals
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • The six killers first — ACS, dissection, PE, tension PTX, Boerhaave, tamponade — then the hs-cTn 0/1h or 0/2h algorithm.
  • Isolated ST depression V1–V3 is posterior OMI until V7–V9 say otherwise.
  • New LBBB alone is not a STEMI equivalent (2025 ACC/AHA); use Sgarbossa/Smith and the patient.
  • Selected patients can meet a validated single very-low hs-cTn rule-out; early presenters or ongoing clinical concern require serial assessment.

Pitfalls

  • Isolated ST depression V1–V3 = posterior OMI until proven otherwise (V7–V9).
  • Wellens / De Winter = critical LAD disease even when pain-free.
  • New or presumed-new LBBB alone is not a STEMI equivalent (2025 ACC/AHA ACS) — use Sgarbossa/Smith criteria and clinical context.
  • Dissection mislabelled as NSTEMI and anticoagulated — check pulses/BP in both arms.
  • Do not default to a 6-hour troponin wait when an hs-cTn 0/1h or 0/2h protocol is available.
  • PE in the young and pregnant — non-tachycardic PE is common.
  • “Musculoskeletal” + risk factors = the classic anchoring error.
  • A cold, pulseless limb with chest or back pain is dissection until the aorta is seen.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Shortness of BreathSyncopeShockNausea & VomitingAcute Limb IschemiaECG Guide

Selected guidance · source check 2026-09-07. These 3 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

Troponin pathways

Identify the assay, symptom timing and the validated pathway used locally. A result inside the reference range is not automatically a complete rule-out.

Source and scope

Supporting teaching points checked 2026-09-10. This is an educational synthesis, not an independently peer-reviewed protocol.

ESC acute coronary syndromes guideline (2023)

Confirm patient context, full recommendations and local policy. External sources need an internet connection.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — cardiac & chest pain chapters
  • 2021 AHA/ACC Chest Pain Guideline; 2022 ACC Expert Consensus Pathway (ED chest pain)
  • 2025 ACC/AHA/ACEP ACS Guideline
  • 2023 ESC ACS Guidelines (0/1h and 0/2h hs-cTn algorithms)
  • 2026 AHA/ACC Acute PE Guideline
Shortness of Breath →