Chest Pain: Thinking Beyond the Heart Attack
Chest pain is one of the most common reasons people call an ambulance or present to an emergency department, and one of the most common OSCE stations. Most chest pain turns out to be something benign, such as a muscle strain or reflux. The challenge is that a small number of patients have a condition that can kill them within hours, and those patients do not always look the sickest. Good chest pain assessment means thinking beyond the heart attack and actively ruling out the dangerous causes.
Pathophysiology
Why chest pain is hard to pin down
The heart, great vessels, oesophagus and lungs share overlapping nerve pathways. Pain from these deep organs is poorly localised and often felt somewhere else, such as the arm, jaw, neck, back or upper abdomen. This is called referred pain, and it is why the location of chest pain alone rarely tells you its cause.
Acute coronary syndrome
Acute coronary syndrome, or ACS, happens when an unstable plaque in a coronary artery ruptures and a clot forms over it. Blood flow to part of the heart muscle drops, and the muscle becomes ischaemic. If the artery is completely blocked, the muscle begins to die, and this shows on the ECG as an ST elevation myocardial infarction, or STEMI. Partial blockage can cause a non ST elevation myocardial infarction or unstable angina. Heart muscle lost is not regained, which is why time to treatment matters so much.
The other killers
Alongside ACS, five other causes of chest pain can be rapidly fatal and are worth knowing as a group:
Aortic dissection: a tear in the inner wall of the aorta, classically causing sudden, severe tearing pain that may radiate to the back.
Pulmonary embolism: a clot in the pulmonary arteries, often with sudden breathlessness, pleuritic pain and a fast heart rate.
Tension pneumothorax: trapped air under pressure in the chest, causing respiratory distress and obstructive shock.
Cardiac tamponade: fluid or blood compressing the heart, causing low blood pressure and distended neck veins.
Oesophageal rupture: a tear in the oesophagus, often after forceful vomiting, causing severe pain and rapid deterioration.
Most chest pain is benign, but your job is to prove that, not assume it.
Assessment and Treatment
Taking the history
A structured pain history such as OPQRST helps: onset, provocation, quality, radiation, severity and time. Sudden, maximal onset suggests dissection or embolism. Crushing or heavy pain spreading to the arm or jaw suggests ischaemia. Pain that changes with breathing or position suggests a pleural or pericardial cause. Ask about risk factors, including smoking, diabetes, high blood pressure, high cholesterol, family history, recent surgery or long travel, and previous heart disease.
Be careful with patients who do not fit the textbook picture. A large study of patients with myocardial infarction found that women were more likely than men to present without chest pain, and patients who presented without chest pain had higher mortality. Older people and people with diabetes may also present with breathlessness, nausea, sweating, fatigue or simply feeling unwell.
Examination and the ECG
Check vital signs, including blood pressure in both arms where dissection is a possibility, as a significant difference can be a clue. Listen to the chest, look for signs of heart failure and check for leg swelling that might suggest a clot. Australian guidelines recommend a 12 lead ECG within 10 minutes of first medical contact for anyone with suspected ACS. A normal first ECG does not rule out ACS, so repeat it, especially if symptoms change.
In practice: a 52 year old woman with diabetes who feels breathless, sweaty and nauseated but denies chest pain still needs a 12 lead ECG. Atypical does not mean low risk.
Treatment priorities
Assess and manage airway, breathing and circulation, and keep the patient at rest.
Acquire and interpret a 12 lead ECG early, and repeat it.
Give oxygen only if saturation is low, as routine oxygen is not recommended in patients with normal saturation.
Manage pain and give ACS treatments according to your clinical practice guidelines and scope of practice.
Recognise STEMI early and notify the receiving hospital, so the patient can go directly to a reperfusion pathway.
Keep the other killers in mind, particularly before giving treatments that could cause harm in dissection.
Conclusion
Chest pain assessment is about risk, not reassurance. Take a structured history, look for atypical presentations, get an early 12 lead ECG and repeat it, and actively consider the life threatening causes beyond ACS. The patient who does not fit the textbook is often the one who needs the most careful assessment.
References
Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Heart Lung Circ. 2016;25(9):895. https://www.mja.com.au/journal/2016/205/3/national-heart-foundation-australia-and-cardiac-society-australia-and-new
Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813.
Chest Pain. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470557/
Australian Commission on Safety and Quality in Health Care. Acute Coronary Syndromes Clinical Care Standard. Sydney: ACSQHC.
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Disclaimer: This article is general education for students. It is not medical advice, and it does not replace your service's clinical practice guidelines, your educators or your local protocols.
