Rapid Review·HY Approach
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Cardiovascular
T1Must knowApproach to Chest Pain
Focus on
Two pathways that must never be confused. Acute chest pain gets an ECG within 10 minutes and serial troponins, with reperfusion activated on ST elevation before any biomarker returns, while the six killers are excluded in parallel. Stable chest pain gets a pretest-probability estimate that decides between no test, a stress test or CT angiography, and angiography. A stress test is never done until ACS is excluded.
Key takeaways
Initial Steps
Stabilize first
an unstable patient is stabilized first (airway, breathing, circulation, disability, exposure).Electrocardiogram (ECG) within 10 minutes
every stabilized patient gets one on arrival, and a chest radiograph.Rule acute coronary syndrome (ACS) in or out
the first priority.Aspirin 325 mg
as soon as possible for suspected ACS with a low risk of aortic dissection.Acute or chronic
stability decides the pathway.- Acute pathway: ongoing pain, hemodynamic compromise, dynamic ECG change or a troponin rise.
- Chronic pathway: predictable, resolved exertional pain in a stable patient.
- The Follow the stable versus acute chest-pain pathways lays out both.
Acute Pathway
The ECG
it has poor sensitivity early.- A normal first ECG: repeat it every 15 to 30 minutes with serial troponin until the picture resolves or confirms.
Sort the syndrome by ECG and troponin
- STEMI: ST elevation in 2 or more contiguous leads, or a new left bundle branch block, is an ST-elevation myocardial infarction (STEMI) and goes to reperfusion; biomarkers never delay it (Acute Coronary Syndrome).
- No ST elevation: an elevated troponin is a non-ST-elevation myocardial infarction (NSTEMI); a normal troponin is unstable angina.
- Normal ECG and troponin, high suspicion: order a non-invasive stress test.
Stable Pathway
Grade the pain
substernal, brought on by exertion, relieved by rest or nitroglycerin.- All three is typical angina, two is atypical, one or none is non-cardiac.
Estimate the pretest probability
from age, sex and the grade, then choose from the table.A positive stress test or CCTA
leads to invasive coronary angiography.- Which stress test and how to read it: Approach to Stress Testing.
| Probability | Clinical scenario | Next step |
|---|---|---|
| Low | Asymptomatic people of any age; atypical chest pain in a woman under 50 | No additional testing |
| Intermediate | Men with atypical angina (any age); women with atypical angina over 50; women with typical angina aged 30 to 50 | Stress test or coronary computed tomography angiography (CCTA) |
| High | Typical angina in men aged 40 or more, or women aged 60 or more | Start pharmacologic therapy for coronary artery disease |
Causes by Pain Quality
Coronary
substernal, precipitated by exertion, relieved by rest or nitroglycerin (Stable Angina).Aortic (dissection, intramural hematoma)
abrupt and maximal at onset, severe and tearing, may radiate to the back; hypertension or an inherited aortopathy (Aortic Dissection).- Hold aspirin and heparin until dissection is excluded.
Pulmonary or pleuritic (pleurisy, pneumonia, pericarditis, pulmonary embolism)
sharp, stabbing, worse with inspiration.- Pericarditis is the pleuritic pain that is worse lying flat (Acute Pericarditis).
Chest wall
persistent pain that often follows repetitive activity, worse with movement or a change of position, and reproducible with palpation.Esophageal disease (GERD), the mimic
gastroesophageal reflux disease (GERD) is favored by non-exertional pain, episodes lasting over 1 hour, post-prandial symptoms, provocation by lying down, associated heartburn or regurgitation, and relief with anti-reflux therapy.Esophageal rupture (Boerhaave syndrome)
severe retrosternal pain and subcutaneous emphysema after vomiting; CT or an esophagram, antibiotics, surgery.| Feature | Coronary | Esophageal |
|---|---|---|
| Trigger | Exertion | Meals, lying down |
| Duration | Minutes | Often over 1 hour |
| Relief | Rest, nitroglycerin | Anti-reflux therapy |
| Associated | Autonomic symptoms | Heartburn, regurgitation |
| Radiation | Epigastrium, arms, jaw, neck, back | The same, so not discriminating |
A 58-year-old has 40 minutes of pressure-like chest pain; the first ECG is normal and the first troponin is negative, but the pain came on with exertion. What happens next, and when is a stress test allowed?
Repeat the ECG every 15 to 30 minutes with serial troponin; give aspirin if dissection is unlikely. A stress test only after ACS is ruled out (ECG and troponins stay normal but suspicion remains).
How it's tested
Chest pain for 40 minutes; ECG shows 3 mm ST elevation in V2 to V5; troponin pending: activate the cath lab now; biomarkers never delay reperfusion.
Chest pain, normal ECG, first troponin normal: repeat the ECG and troponin at 1 to 3 hours; one normal set excludes nothing.
Sudden tearing chest pain radiating to the back, blood pressure 190/110 with a 25 mm Hg difference between arms: aortic dissection; CT angiography; hold the aspirin and heparin; esmolol.
A 45-year-old woman with atypical chest pain and a normal ECG who can exercise: intermediate probability; exercise ECG stress test.
A 62-year-old man with textbook exertional angina: high probability; treat as coronary disease; a negative stress test would not change that.
Sharp pain worse on inspiration, better sitting forward, a rub and diffuse ST elevation with PR depression in a 24-year-old after a cold: pericarditis; non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, not the cath lab.
Substernal burning an hour after large meals, worse lying down, with regurgitation; ECG and troponins normal: esophageal pain; radiation to the arm would not have excluded the heart; a proton pump inhibitor trial once cardiac disease is excluded.
Severe retrosternal pain and subcutaneous emphysema after vomiting: Boerhaave syndrome; CT or esophagram, antibiotics, surgery.
Go deeper
Guidelines: 2021 AHA/ACC Chest Pain Guideline · 2025 ACC/AHA Acute Coronary Syndromes Guideline
Related Step 2 pages: Acute Coronary Syndrome, Stable Angina, Approach to Stress Testing, Aortic Dissection, Acute Pericarditis, Obstructive Shock, Cardiac Tamponade, ECG Basics
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