Cardiology
Approach to chest pain
Written 30 September 2026. This date is not a physician-review date.
Why this matters
Chest pain is common. A few causes kill quickly, and they do not all look like a heart attack.
Rapid clinical summary
- First decide whether the patient is unstable.
- Then look for the causes you cannot send home: coronary occlusion, pulmonary embolism, dissection, pneumothorax, and esophageal rupture.
- A normal oxygen saturation does not exclude ischemia.
Mechanism
Pain fibers from the heart, aorta, pleura, and esophagus share pathways. The history is about character, timing, and associated collapse or breathlessness — not about how worried the person looks.
Recognition
If you cannot say why this pain is safe, it is not safe yet.
Typical
- Pressure with exertion
- Pleuritic pain with breathlessness
- Tearing pain to the back
- Pain after vomiting
Red flags
- Ongoing pain
- Shock
- Sudden breathlessness
- A new neurological deficit with the pain
- Unequal pulses
Differential
| Condition | Clue | Trap |
|---|---|---|
| Acute coronary syndrome | Pressure, sweat, exertion | Waiting for a troponin before the ECG |
| Pulmonary embolism | Sudden dyspnea, pleuritic pain, a risk | Calling every clear chest an infection |
| Aortic dissection | Tearing pain, pulse deficit, neurological change | Treating it as infarction and giving the wrong drug pathway |
| Pneumothorax | Sudden pleuritic pain, reduced breath sounds | A chest X-ray that was never done |
| Esophageal rupture | Pain after vomiting, subcutaneous air | Labeling it reflux because it followed a meal |
Investigations
- ECG immediately when ischemia is possible.
- The next test follows the leading dangerous diagnosis. It is not the same test for every chest pain.
Management
- Immediate
- Support airway, breathing, and circulation if any of those are failing. Get the ECG if the story could be cardiac.
- Definitive
- The definitive step is the one that matches the diagnosis: reperfusion for occlusion, a surgical pathway for dissection or rupture, drainage for a tension pneumothorax. This page does not state drug doses.
- Monitoring
- Repeat the assessment if pain, blood pressure, or conscious level changes. One set of normal observations does not retire the diagnosis.
Common pitfalls
- Using oxygen saturation as a test for ischemia.
- Discharging ongoing pain.
- Forcing every chest pain down a single ACS pathway.
Exam reasoning
Exams often ask for the next step, not the full differential. Stability and the one finding that does not fit are the discriminator.
Practice this topicOpens original Mahazanaka questions in this subject. If this subject is thin on that track, the session uses what exists.
Visual summary
Five dangerous causes before a benign label.
Recognize, reason, prioritize, act safely
- Recognize. Pain plus a time course and one associated feature.
- Reason. Which structure could kill in the next hour?
- Prioritize. Unstable features before a complete list of benign causes.
- Act safely. The test or treatment that addresses that structure. Not a routine clinic.
Knowledge check
A patient has ongoing chest pressure and a normal oxygen saturation. Is it reasonable to send them home without an ECG?
Tearing pain to the back and a pulse deficit. Why is an automatic ‘heart attack drug pathway’ the wrong reflex?
No citation is attached to this chapter. Nothing here is personal medical advice.