Notice: this content is AI-generated and has not yet been fully reviewed by the author. Do not rely on it for patient care — always verify against the linked guidance and your seniors.
A revision walkthrough — for learning, not live patient decisions. In real practice, chest pain is always a senior-supported, local-guideline call. Start the walkthrough
● worked example · learn the approach

Chest pain

Learn to think through chest pain, step by step. A calm walkthrough of how the assessment flows in the ED — what to look for, what not to miss, and how the plan comes together. Built for revision and understanding, not for live patient decisions.

1

Settle them, and check the basics

all at once, calmly

If any of these are here, get help now — then come back

Looks unwell / unstableany killer — resuscitate first STEMI or new LBBB on ECGacute coronary syndrome Tearing pain, unequal arm BPsaortic dissection Sudden pleuritic pain + hypoxiaPE or pneumothorax New murmur, muffled sounds, raised JVPdissection or tamponade Syncope with the chest painmassive PE or dissection
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Pearl

First question, always: sick or not sick? Look at them from the end of the bed, get them on a monitor, get the ECG. If your gut says unwell — you've already picked up the phone. That's the right call every time.

Your first moves — all at once, calmly

  • A–EAssess A–E, sit them uptreat what kills first as you find it
  • ◔Full obs + continuous monitoringHR · BP in both arms · SpO₂ · RR · temp
  • ♥12-lead ECG within 10 minutes of arrivalrepeat if the pain changes — NICE CG95
  • ✚IV access + bloods including hs-troponinFBC, U&E, glucose, ± D-dimer once scored (step 3)
  • ℞Aspirin 300 mg if ACS suspectedunless clear allergy — NICE NG185
  • O₂Oxygen only if SpO₂ < 94%target 94–98%, or 88–92% if COPD risk
2

Understand the pain & the person

the story does the heavy lifting

Take a focused history — the pain character routes you

  • Cardiac — central, heavy, exertional, radiates to jaw/arm → ACS
  • Pleuritic — sharp, worse on inspiration → PE, pneumonia, pneumothorax
  • Tearing — sudden, maximal at onset, to the back → dissection
  • Positional — worse flat, better sitting forward → pericarditis

Risk that shifts the odds: cardiac (age, IHD/PCI/CABG, diabetes, smoking, family history, cocaine); VTE (surgery, immobility, cancer, previous VTE, pregnancy, oestrogen).

Work A–E — assess and act as you go

This is your calm backbone: examine top to bottom, and at each step you're both sorting between the killers and treating what you find. You don't wait until the end to act.

AAirway / voice. Neck crepitus or a voice change after vomiting → oesophageal rupture.secure airway, high-flow O₂ if compromised, keep nil by mouth
BBreathing. One-sided absent breath sounds + hyper-resonance → tension pneumothorax. Clear chest but hypoxic and tachypnoeic → PE. Crackles / bronchial breathing → pneumonia.SpO₂, O₂ if <94%; if tension pneumothorax, decompress now — don't wait for imaging
CCirculation. BP different between arms or a new early-diastolic murmur → dissection. Muffled sounds + raised JVP + hypotension → tamponade. Pericardial rub → pericarditis.IV access + bloods; dissection → rate/BP control, no anticoagulation; tamponade → urgent echo
DDisability. Focal neurology or syncope with chest pain → dissection or massive PE, not a benign cause.check glucose, escalate early
EExposure. A hot, swollen, unilateral calf → DVT and a strong nudge toward PE. Fever → infective causes.examine both legs, temperature; anticoagulate once PE confirmed
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Pearl

A normal first ECG on a well-looking patient does not clear ACS, dissection or PE. Take the history properly before the troponin comes back — it's telling you where to look.

3

Gently rule out the six killers

tap to open each

Each card gives you what points toward it, what would rule it in, what lets you stand it down, and how to manage it once it's confirmed.

Then the common, kinder causes

Once the killers are handled: musculoskeletal / costochondritis (reproducible on palpation), GORD / oesophageal spasm, pneumonia, anxiety. Reproducible tenderness leans MSK, but never rules out a killer by itself.

4

Investigate — what to order, when, and what it tells you

test with a question in mind

12-lead ECG

When
Immediately, within 10 minutes. Repeat with any change in pain, and serially if concern persists.
Tells you
STEMI or new LBBB (act now), ischaemia (ST depression, T inversion), pericarditis (widespread saddle ST + PR depression), or RV strain suggesting PE.
Trap
A normal ECG does not exclude ACS. It's a snapshot — repeat it.

High-sensitivity troponin

When
At presentation, then repeat on your lab's ESC 0/1-hour (preferred) or 0/2-hour pathway. Cut-offs are assay-specific — use your local numbers.
Tells you
Myocardial injury. A significant rise/fall (delta) with a compatible story supports MI; a low value with minimal delta and a non-ischaemic ECG supports rule-out.
Trap
A raised troponin is not automatically ACS — it also rises in PE, sepsis, renal failure, myocarditis and tachyarrhythmia. Interpret with the ECG and the story, never alone.

D-dimer

When
Only after a pre-test probability score. For PE: "unlikely" Wells (≤4). Never as a blind screen, and never if PE is "likely" (go straight to CTPA).
Tells you
A negative age-adjusted D-dimer in a low-risk patient safely excludes PE.
Trap
It's non-specific — raised by infection, malignancy, pregnancy, surgery and age. A positive result in someone low-risk just earns them an unnecessary CT.

Chest X-ray

When
Early in most undifferentiated chest pain.
Tells you
Pneumothorax, consolidation, effusion, pulmonary oedema, or a widened mediastinum (a clue to dissection).
Trap
Often normal in PE — a clear film doesn't reassure you there.

Definitive imaging & bedside tests

CTPA
If PE is "likely" or D-dimer positive — confirms or excludes PE.
CT aortogram
If dissection is suspected — the definitive test.
Echo
For suspected tamponade, dissection complications, RV strain, or an unstable patient.
VBG / lactate
If the patient is unwell — perfusion, oxygenation, acid-base.
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Pearl

Every test should answer a question you've already asked. "What am I ruling in or out with this, and what will I do with each result?" If you can't answer that, you probably don't need the test yet.

5

How the plan comes together

disposition · handover

You've excluded the killers and investigated. The closing question for any chest pain is simple: how high-risk is this, and where does the patient go?

discharge

Killers excluded, low-risk, negative serial troponin, non-ischaemic ECG.

Safety-net: clear return advice, GP follow-up, document the reasoning.

admit / observe

Awaiting serial troponin, higher risk, or the diagnosis unresolved.

Hand over: working diagnosis, what's outstanding, what would change the plan.

Risk-stratifying the chest pain patient — the HEART score

One validated tool that supports the admit-vs-discharge call, built from five things each scored 0–2: History, ECG, Age, Risk factors, Troponin.

0–3 · low
low risk of a major adverse cardiac event over ~6 weeks; with a non-ischaemic ECG and negative serial troponin, many pathways support discharge with safety-netting.
4–6 · moderate
admit or observe for serial troponin and senior review.
7–10 · high
high risk — managed actively with senior and cardiology input.

It guides the decision — it never replaces clinical judgement or local policy.

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Pearl

Your handover is part of the plan. One clean line — "chest pain, killers considered and why, troponin pending at X, my worry is Y, escalate if Z" — is what keeps them safe overnight. Nicely done getting here.