Chest pain
Exam Tips
- In OSCEs, state early that your first priority is excluding life-threatening causes before pursuing common benign diagnoses.
- A normal resting ECG does not rule out coronary disease; integrate serial history, risk profile, and troponin strategy.
- Ask whether pain is exertional, pleuritic, positional, or reproducible on palpation; this quickly narrows differentials.
- Always check blood pressure in both arms when dissection is possible and look for pulse deficits/new diastolic murmur.
- Use visual revision aids: coronary pain radiation maps, Beck's triad diagrams, and CT images showing aortic intimal flap and PE filling defects.
Definition
Chest pain is pain perceived within the thorax and is a symptom rather than a single diagnosis; in UK practice it must first be stratified into potentially life-threatening versus non-urgent causes. Clinically, the key task is to rapidly identify serious pathology (for example acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, or tamponade) while considering common primary care causes such as musculoskeletal, gastrointestinal, and anxiety-related pain.
Pathophysiology
Chest pain arises from activation of visceral and somatic afferent pathways. Cardiac ischaemia causes metabolite-driven stimulation of sympathetic/visceral fibres (T1-T5), producing central pressure-like pain with referred radiation to arm, jaw, or back; pleural, pericardial, and chest wall inflammation causes sharper, localised pain via somatic intercostal/phrenic innervation and is often pleuritic or reproducible. Other mechanisms include mechanical stretch/tear (aortic dissection), increased pulmonary vascular resistance and pleural irritation (PE), acid-mediated oesophageal nociception/spasm (GORD/oesophageal causes), and central amplification in anxiety or panic disorders.
Risk Factors
- Older age
- Male sex
- Smoking
- Hypertension
- Diabetes mellitus
- Raised LDL-cholesterol or mixed dyslipidaemia
- Family history of premature cardiovascular disease
- Known coronary artery disease or previous myocardial infarction
- Chronic kidney disease
- Cocaine or stimulant use
- Recent immobility, surgery, active cancer, or prior venous thromboembolism (PE risk)
- Connective tissue disease or known aortic aneurysm (dissection risk)
Clinical Features
Symptoms
- Central/band-like chest pressure, often radiating to jaw, arm(s), shoulder, or back (suggests cardiac ischaemia)
- Pain precipitated by exertion and relieved by rest or glyceryl trinitrate (typical stable angina pattern)
- Sudden severe tearing pain to interscapular back (consider aortic dissection)
- Sharp pain worse on inspiration/cough (pleuritic pattern: pulmonary, pleural, pericardial, or musculoskeletal)
- Sharp constant retrosternal pain relieved by sitting forward and worse lying flat (pericarditis pattern)
- Associated breathlessness, diaphoresis, nausea, presyncope/syncope, or palpitations
- Dysphagia or reflux symptoms suggest oesophageal source
- Localised persistent pain after strain/trauma suggests chest wall source
Signs
- Pallor, clamminess, distress, or hypotension (possible shock)
- Blood pressure difference between arms or pulse deficits (aortic dissection red flag)
- Tachycardia, bradycardia, or irregular pulse (arrhythmia/haemodynamic compromise)
- New murmur (including aortic regurgitation in dissection) or pericardial friction rub
- Raised JVP, muffled heart sounds, pulsus paradoxus (tamponade features)
- Basal crackles, wheeze, peripheral oedema (acute heart failure pattern)
- Hypoxia or tachypnoea; unilateral pleural findings (pulmonary causes)
- Reproducible chest wall tenderness on palpation/movement (musculoskeletal source)
- Unilateral calf swelling/tenderness (possible DVT with PE)
- Fever or rash (infection, shingles)
Investigations
Management
Lifestyle Modifications
- Treat as a time-critical symptom: urgent transfer for suspected life-threatening causes; do not delay referral for non-essential community tests.
- Smoking cessation, Mediterranean-style diet, regular physical activity, and weight optimisation for long-term cardiovascular risk reduction.
- Optimise BP, glycaemic control, and lipid management; address alcohol excess and stimulant drug use.
- Safety-net clearly: call 999 for persistent (>15 minutes), recurrent, or severe chest pain, syncope, or breathlessness.
Pharmacological Treatment
Immediate suspected acute coronary syndrome (pre-hospital/initial)
- Aspirin 300 mg chewed once
- Glyceryl trinitrate sublingual spray 400 micrograms, repeat every 5 minutes up to 3 doses if pain persists and blood pressure allows
- Morphine sulfate 2.5-5 mg IV titrated in small increments for severe pain (with antiemetic such as metoclopramide 10 mg IV)
Do not give aspirin if true aspirin hypersensitivity or active major bleeding. Avoid nitrates with phosphodiesterase-5 inhibitors (for example sildenafil within 24 hours, tadalafil within 48 hours), in marked hypotension, or suspected right ventricular infarction. Oxygen is not routine; give if hypoxic (target usually 94-98%, or 88-92% if risk of hypercapnic respiratory failure). If aortic dissection is suspected, avoid antiplatelet/anticoagulant escalation until imaging confirms diagnosis.
Anti-anginal therapy for stable ischaemic pattern
- Glyceryl trinitrate 400-800 micrograms sublingual as required
- Bisoprolol 5-10 mg once daily
- Amlodipine 5-10 mg once daily
Start one first-line anti-anginal (beta-blocker or calcium-channel blocker) and individualise. Avoid beta-blockers in severe bradycardia, high-grade AV block, or uncontrolled asthma; avoid combining verapamil with beta-blockers due to bradycardia/heart block risk.
Secondary prevention when coronary disease confirmed
- Atorvastatin 80 mg nightly
- Aspirin 75 mg once daily long term (or clopidogrel 75 mg once daily if aspirin unsuitable)
Check bleeding risk and drug interactions for antiplatelets. Monitor liver enzymes and adverse effects with high-intensity statins.
Non-cardiac cause-directed examples
- Omeprazole 20 mg once daily (for likely reflux-related chest pain)
- Ibuprofen 400 mg three times daily short course for musculoskeletal pain, if appropriate
Use NSAIDs cautiously or avoid in established IHD, heart failure, CKD, peptic ulcer disease, or anticoagulated patients. Reassess if symptoms persist or red flags emerge.
Surgical / Interventional
- Urgent percutaneous coronary intervention (PCI) for STEMI/high-risk ACS; CABG in selected multivessel/left main coronary disease
- Emergency cardiothoracic repair (open or endovascular) for acute aortic dissection
- Pericardiocentesis for cardiac tamponade
- Intercostal drain insertion for significant pneumothorax when indicated
Complications
- Myocardial infarction with arrhythmias
- Acute left ventricular failure/cardiogenic shock
- Sudden cardiac death
- Aortic rupture, stroke, or end-organ ischaemia in dissection
- Obstructive shock from cardiac tamponade
- Respiratory failure in severe pulmonary causes
- Recurrent emergency attendance and functional impairment from untreated non-cardiac chest pain
Prognosis
Prognosis is cause-dependent: benign musculoskeletal or reflux-related pain often improves with targeted treatment, whereas missed ACS, PE, dissection, or tamponade carries high early mortality. Early recognition of red flags, rapid referral, and risk-factor modification substantially improve outcomes in UK clinical pathways.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Chest pain[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 424, 425)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1087)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 523)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 426)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 527)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 277, 278)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 276, 277)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 277, 278)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 296)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 120)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 593, 594)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 32)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 110)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 189)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 109, 110)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 127)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 537)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1403)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 94)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 843)[context]