Chest Pain

🔍 When to Suspect

A common presentation with a wide differential; requires rapid assessment to distinguish cardiac emergencies from non-cardiac or benign causes

From the full topic in The Ocean Library: Chest Pain

🧭 When to suspect

Chest pain is one of the most common reasons for urgent primary-care contact, and it spans a vast differential – from benign musculoskeletal or oesophageal pain to immediately life-threatening acute coronary syndrome (ACS), pulmonary embolism (PE) and aortic dissection. The first task is not to reach a precise diagnosis but to decide, quickly, who needs emergency admission and who can be assessed in slower time.

Two features dominate that decision: the timing of the pain (is it present now, and did it start within the last 12 hours?) and the 12-lead ECG. Suspect ACS with central, heavy or crushing pain that radiates to the arm(s) or jaw, occurs at rest or on minimal exertion, and carries autonomic features (sweating, nausea, breathlessness). Suspect stable angina when pain is predictably brought on by exertion and relieved within minutes by rest or GTN. Crucially, do not use the response to GTN to decide whether pain is cardiac – it relieves oesophageal spasm too.

Pain pattern	Most suggestive cause
Central, heavy or crushing; radiates to arm(s)/jaw; at rest or minimal exertion; sweating, nausea, breathlessness	Acute coronary syndrome
Predictable and exertional; relieved within minutes by rest or GTN	Stable angina
Sudden, severe, tearing; radiates through to the back; may have unequal arm blood pressures	Aortic dissection
Sudden and pleuritic; with breathlessness or tachycardia; VTE risk factors	Pulmonary embolism
Sharp, pleuritic and positional; eased by sitting forward	Pericarditis
Reproduced by palpation or movement; localised	Musculoskeletal
Burning, postprandial; acid taste or regurgitation; eased by antacids	Gastro-oesophageal reflux

🧠 Clinical pearl The classic pattern can be absent. Older people, women and people with diabetes may have a myocardial infarction with little or no chest pain – breathlessness, fatigue, nausea, sweating or simple collapse may be the only clue. Keep the threshold for an ECG low in these groups, because the "textbook" history that triggers admission may never appear.

Source: NICE CG95 · NICE NG185

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