🩺 Chest Pain

Chest pain is one of the most common presentations to UK Emergency Departments and General Practice. It encompasses a broad spectrum of pathologies ranging from benign musculoskeletal issues to life-threatening cardiovascular emergencies. The primary goal of the initial assessment is to differentiate between cardiac, pulmonary, and gastrointestinal causes while prioritising the identification of Acute Coronary Syndrome (ACS). Management requires a risk-stratified approach guided by clinical findings, ECG, and biomarkers.

A detailed SOCRATES assessment is essential. Cardiac pain is typically retrosternal, heavy/crushing, and radiates to the jaw or left arm, often worsened by exertion and relieved by rest or GTN. Pleuritic pain (sharp, worse on inspiration) suggests PE, pneumonia, or pericarditis. Sudden-onset 'tearing' pain radiating to the back is a classic red flag for aortic dissection. Ask about associated autonomic symptoms like diaphoresis, nausea, and vomiting, as well as risk factors including smoking, hypertension, and family history.

Initial assessment follows the ABCDE approach to ensure stability. Cardiac auscultation may reveal S4 (ischaemia), S3 (heart failure), or a new systolic murmur (mitral regurgitation/VSD post-MI). Lung auscultation is vital to check for pulmonary oedema or diminished breath sounds (pneumothorax). Peripheral examination should include palpating all pulses (asymmetry in dissection) and checking for calf tenderness or swelling (DVT leading to PE). JVP elevation may suggest right heart strain or heart failure.

Acute Coronary Syndrome (STEMI, NSTEMI, Unstable Angina), Pulmonary Embolism, Aortic Dissection, Gastro-oesophageal Reflux Disease (GORD), Musculoskeletal (Costochondritis), Pericarditis, Tension Pneumothorax.

Tearing pain radiating to the back (dissection); sudden onset pleuritic pain with hypoxia (PE or pneumothorax); drenching sweats and pallor (autonomic response to MI); hypotension or new-onset tachycardia; new-onset heart failure symptoms.

A 12-lead ECG is the priority and should be performed within 10 minutes; look for ST-elevation (STEMI), ST-depression/T-wave inversion (NSTEMI/Angina), or S1Q3T3 (PE). Serial high-sensitivity troponins are used to detect myocardial necrosis. A chest X-ray is necessary to look for a widened mediastinum (dissection), congestion (HF), or consolidation (pneumonia). Further tests may include D-dimer (if PE suspected and Wells score low), CTCA for stable angina, or CTPA for suspected PE.

Standard practice for chest pain of suspected cardiac origin includes the 'rule-in/rule-out' troponin pathways (0/1 or 0/3 hour). Always consider the 'big five' life-threatens: ACS, PE, aortic dissection, tension pneumothorax, and oesophageal rupture. In stable patients, the NICE clinical likelihood score helps determine if CT coronary angiography (CTCA) is required. Be wary of 'silent MI' in elderly or diabetic patients who may present with only dyspnoea or syncope.

Aligned with the Cardiovascular and Respiratory sections of the MLA Content Map. Emphasises the recognition of acute emergencies and the tiered approach to diagnostic imaging. Management focuses on the immediate stabilisation (MONA: Morphine, Oxygen [if hypoxic], Nitrates, Aspirin) and appropriate referral pathways.