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Approach to acute chest pain in the emergency department
In acute chest pain, first look for the six causes that kill — acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, tamponade and oesophageal rupture — using an ECG within 10 minutes, high-sensitivity troponin and a focused history, and only then accept a benign explanation.
Why it matters in the exam
Chest-pain questions test the next decision: a first ECG within 10 minutes, interpreting high-sensitivity troponin with a 0/1- or 0/2-hour protocol, and using a risk tool (HEART) to decide on discharge. A common distractor is giving antiplatelets or anticoagulants before dissection has been excluded when it is clinically suspected.
Classic pictures are also asked: tearing pain to the back with a blood-pressure difference between the arms (dissection), sudden breathlessness with tachycardia (embolism), pain after repeated vomiting with subcutaneous air (Boerhaave), and pain relieved by sitting forward with diffuse ST elevation (pericarditis).
Exam questions often show a young patient with atypical pain and a normal ECG, or an older patient with vague symptoms, and the decision is whether to discharge, observe or image. The key is to combine three things: the clinical pre-test probability, the high-sensitivity troponin result over time and a validated risk tool. A rising troponin without ECG changes defines a non-ST-elevation infarction.
Key points
- Six lethal causes: ACS, dissection, embolism, tension pneumothorax, tamponade, oesophageal rupture.
- ECG within 10 minutes of arrival.
- High-sensitivity troponin with a 0/1- or 0/2-hour protocol.
- Low HEART (0–3) with negative troponins — safe discharge.
- Suspected dissection — CT angiography before any anticoagulant treatment.
Summary table
| Life-threatening cause | Key clue | Deciding test |
|---|---|---|
| Acute coronary syndrome | Exertional pressure, radiation, risk factors | ECG within 10 minutes, serial high-sensitivity troponin |
| Aortic dissection | Tearing pain to the back, pulse deficit, pressure difference | CT angiography (TEE if less stable) |
| Pulmonary embolism | Sudden breathlessness, tachycardia, thrombotic risk factors | Wells or YEARS, D-dimer, CT pulmonary angiography |
| Tension pneumothorax | Absent breath sounds, hypotension, full neck veins | Clinical diagnosis; POCUS |
| Tamponade | Beck triad, pulsus paradoxus | Cardiac POCUS |
| Oesophageal rupture (Boerhaave) | Vomiting followed by pain, subcutaneous emphysema | CT with water-soluble oral contrast |
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Sources
- ESC Guidelines for the management of acute coronary syndromes, 2023 — Diagnosis: high-sensitivity troponin algorithms
- AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain, 2021 — Acute chest pain in the emergency department
- ESC Guidelines for the diagnosis and management of acute pulmonary embolism, 2019 — Diagnostic strategies
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.