Chest Pain ❤️🔥
Clinical guide for assessing and managing chest pain. Differential diagnosis, ECG interpretation, ACS protocols, and emergency management for on-call doctors.
HEART Score
Risk stratification for suspected ACS in the ED (HEART score; Backus et al.). Educational aid only — follow local pathways.
History
How suspicious is the chest pain for ACS?
ECG
Initial ED tracing.
Age
Risk factors
HTN, dyslipidaemia, DM, obesity, smoking, FH of CAD <65y; ≥3 factors OR known atherosclerotic disease scores 2.
Troponin
Relative to local assay upper reference limit (URL).
Total HEART score
—
HEART score derivation and validation are reported by Dr Barbra Backus and colleagues (see primary literature, e.g. Crit Pathw Cardiol / related ED chest pain series). Interpretation thresholds vary slightly between studies; always combine with clinical judgement, serial troponins, and hospital protocol.
🧠 Differential Diagnosis
- Acute Coronary Syndrome (ACS) – Most important to rule out. May present atypically (nausea, dyspnoea, back pain). Risk factors: age, smoking, HTN, DM, IHD.
- Aortic Dissection – Sudden tearing chest/back pain, often interscapular. Pulse deficits or BP difference. Urgent CT-A.
- Pulmonary Embolism (PE) – Sudden pleuritic pain, tachypnoea, tachycardia, hypoxia. Consider Wells Score/D-dimer/CTPA.
- Pericarditis – Sharp or dull pain, often relieved by sitting forward. May have pericardial rub or ECG changes (diffuse ST elevation).
- Gastro-oesophageal – GORD, oesophageal spasm. Consider if burning or post-prandial.
- Pneumothorax – Especially in COPD patients or post-central line. Absent breath sounds, hyperresonance.
- Other causes – Anxiety, costochondritis, musculoskeletal, herpes zoster (prior to rash).
📞 When Called
- Ask for current vitals, oxygen saturation, and pain level.
- Check if ECG has been done — request one if not.
- Ask about history of IHD, current meds
- Find out if the patient has IV access.
- Review sign-out or medical notes for relevant background.
🧾 History
- Onset, duration, character of pain (sharp, pressure, burning?)
- Any radiation (jaw, left arm, back)?
- Associated symptoms: sweating, dyspnoea, nausea, syncope?
- Previous episodes? Exertion-induced?
- Cardiac risk factors: HTN, DM, smoking, FHx, prior MI?
🩺 Examination
- General appearance: distress, pallor, diaphoresis?
- Vital signs: HR, BP (both arms if suspect dissection), RR, SpO₂, Temp
- Heart sounds, JVP, chest auscultation (creps, wheeze, rub)
- Peripheral pulses (radio-femoral delay, pulse deficit)
- Check for signs of DVT if suspect PE
🔍 Investigations
- 12-lead ECG – compare with previous if possible.
- Bloods: Troponin, FBC, U&Es, CRP, Coag, D-dimer (if indicated)
- CXR – rule out pneumothorax, heart failure, mediastinal widening.
- CTPA or CT Aorta depending on suspicion.
- ABG if hypoxic or unwell
💊 Initial Management
- STEMI: Call STEMI team immediately. Give Aspirin 300mg chewed, plus P2Y12 inhibitor (e.g. Ticagrelor 180mg). Oxygen only if SpO₂ <90%. Nitrates and morphine if needed (avoid in hypotension/RV infarct).
- NSTEMI/ACS: Cardiology referral, dual antiplatelets (e.g. Aspirin + Ticagrelor), LMWH, beta-blockers, statins.
- PE: Anticoagulate (LMWH/DOAC) unless contraindicated. Thrombolysis if massive PE.
- Pneumothorax: Needle decompression if tension PTX. Otherwise, CXR-guided management.
- Pericarditis: NSAIDs, colchicine if no contraindications.
- Provide O₂ if SpO₂ <92%. Reassess regularly.
Related NICE guidance
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
External resources
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:08 ATRP re: chest pain Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [CAD, hypertension, hyperlipidaemia, smoking] 🧾 Hx: • Onset, character, radiation and duration • Associated symptoms: dyspnoea, diaphoresis, nausea • Exacerbating and relieving factors • Previous episodes or cardiac history 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • Cardiovascular exam: heart sounds, JVP • Respiratory exam: breath sounds, crepitations • Signs of heart failure or shock 📋 Impression: Likely cause: [ACS / angina / PE / musculoskeletal / other] 📌 Plan: • ECG and cardiac enzymes • Oxygen if hypoxic • Analgesia and nitrates if appropriate • Antiplatelets and anticoagulation as indicated • Admit for monitoring and further management 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer