⚠️ In patients with significant chest pain, always consider the “big 3” killers: ❤️ Acute Coronary Syndrome (MI), 🫁 Pulmonary Embolism, and 🩻 Aortic Dissection. 👉 In hospitalised patients, PE is often the biggest concern. 🔑 Key acute tests: ECG, Troponin, D-dimer, and CTPA/Aortogram.

🚨 Acute Management of Chest Pain

Always assume chest pain = potentially life-threatening until proven otherwise. Apply ABCDE and treat reversible causes early. ⚡

1️⃣ Immediate Actions

🛏️ Place patient on bed with monitoring (ECG, SpO₂, BP, HR, RR, temp).
💉 Gain IV access (large bore) and take bloods (FBC, U&E, CRP, troponin, D-dimer, glucose, clotting).
💨 Oxygen only if hypoxic (SpO₂ <94%).
🩺 Brief history + exam focused on red flags (shock, collapse, severe SOB, unequal pulses).
📸 Immediate 12-lead ECG (ideally within 10 min of arrival).

📖 Introduction

Chest pain is one of the most common and high-risk acute presentations in medicine. It may reflect a benign musculoskeletal issue, but can also signal life-threatening conditions such as myocardial infarction, pulmonary embolism, or aortic dissection. A structured approach - focusing on history, risk factors, examination, and early investigations - is essential to avoid missed diagnoses.

📝 History

⏱ Onset & Timing: Sudden vs gradual, duration, constant vs intermittent.
📍 Character & Location: Crushing, sharp, pleuritic, retrosternal, localised.
↔️ Radiation: Arm, jaw, back, epigastrium.
⚡ Associated Symptoms: SOB, syncope, sweating, palpitations, nausea, haemoptysis.
⚠️ Red flags: Collapse, hypotension, neurological signs, haemodynamic instability.
❤️ Risk factors: Smoking, hypertension, diabetes, hyperlipidaemia, FHx IHD.
💊 Medications: Anticoagulants, recent steroids/NSAIDs (risk of PUD perforation).
🧠 Context: Exercise, stress, trauma, recent infection, immobilisation.

👩‍⚕️ Examination

🩺 General: ABCDE, vital signs (HR, BP both arms, O₂ sats, RR, temp).
👀 Inspection: Pallor, diaphoresis, distress, scars, trauma signs.
💓 Cardiac: JVP, heart sounds, murmurs, pulse character, pericardial rub.
🫁 Respiratory: Chest expansion, percussion, breath sounds, wheeze, crackles.
🦴 MSK: Localised tenderness, reproducible pain on palpation/movement.
🧠 Other: Neurological exam if collapse/weakness; abdominal exam if epigastric pain.

🩺 Acute Chest Pain – Key Differentials

Condition	Key Features	Investigations	Management
❤️ MI / ACS	Crushing pain >20min, radiates to arm/jaw, sweats, SOB	ECG: ST ↑ / new LBBB, Troponin ↑	Aspirin + DAPT, PCI/thrombolysis, β-blocker, ACEi
💔 Angina	Exertional tightness, relieved by rest/GTN	ECG: ST ↓ on exertion	GTN, β-blocker, CCB, aspirin, lifestyle changes
🫁 Pulmonary Embolism	Sudden pleuritic pain, dyspnoea, tachycardia, hypoxia	D-dimer, CTPA (gold std), V/Q scan	LMWH/DOAC, O₂, thrombolysis if massive
🌬️ Pneumothorax	Sudden pain + SOB, ↓ breath sounds, hyper-resonant	CXR, ABG	Needle decompression if tension, chest drain, observe small
🔥 Pneumonia	Pleuritic pain, cough, fever, crackles	CXR, FBC, sputum culture	Antibiotics, O₂, fluids, vaccines
🩻 Aortic Dissection	Tearing pain → back, pulse/BP asymmetry	CTA chest (gold), TEE if unstable	Type A: surgery; Type B: IV β-blocker
🌀 Pericarditis	Sharp pain, worse lying, better sitting forward, rub	ECG: diffuse ST ↑, PR ↓; Echo	NSAIDs, colchicine, steroids if autoimmune
🍽️ GORD	Burning retrosternal pain, worse lying, antacid relief	Clinical, OGD if red flags	PPIs, lifestyle changes
🦴 MSK (Costochondritis)	Localised, reproducible tenderness	Clinical, normal imaging	NSAIDs, physio, rest
🌡️ Pleuritis	Sharp stabbing pleuritic pain ± viral/autoimmune	CXR, autoimmune screen	NSAIDs, treat underlying cause
😰 Panic Disorder	Chest pain + palpitations, SOB, dizziness, doom	Clinical (exclude cardiac first)	CBT, SSRIs, breathing retraining

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Chest Pain