Some Causes of Chest Pain

Cause*	Suggestive Findings	Diagnostic Approach†
Cardiovascular
Myocardial ischemia (acute myocardial infarction/unstable angina/ angina)	Acute, crushing pain radiating to the jaw or arm Exertional pain relieved by rest (angina pectoris) S4 gallop Sometimes systolic murmurs of mitral regurgitation Often red flag findings‡	Serial ECGs and cardiac biomarkers Sometimes echocardiogram (traditional, POCUS, or both) Stress imaging test or CT angiography considered in patients with negative or unchanged ECG findings and no cardiac biomarker elevation on serial testing Often heart catheterization and coronary angiography if findings are positive
Thoracic aortic dissection	Sudden, tearing pain radiating to the back Some patients have syncope, stroke, or leg ischemia Pulse or blood pressure that may be unequal in extremities Age > 55 years Hypertension Red flag findings‡	D-dimer in patients who are at low risk Chest radiograph, which may reveal widening of the mediastinum In patients who are hemodynamically stable: CT angiogram, possibly subsequent MR angiography or TEE In patients who are hemodynamically unstable: bedside TEE
Myocarditis	Fever, dyspnea, fatigue, chest pain (if myopericarditis), recent viral or other infection Sometimes findings of heart failure, pericarditis, or both	ECG Serum cardiac biomarkers ESR C-reactive protein Usually echocardiography or cardiac MRI
Pericarditis	Constant or intermittent sharp pain often aggravated by breathing, swallowing food, or supine position and relieved by sitting or leaning forward Pericardial friction rub Jugular venous distention (if constrictive pericarditis or large or rapidly accumulating pericardial effusion)	ECG Serum cardiac biomarkers (sometimes showing minimal elevation of troponin and CK-MB levels if associated myocarditis present) Transthoracic echocardiogram to evaluate for pericardial effusion
Gastrointestinal
Esophageal rupture	Sudden, severe pain following vomiting or instrumentation (eg, esophagogastroscopy or transesophageal echocardiography) Subcutaneous crepitus detected during auscultation Red flag findings‡	Chest radiography Esophagography with water-soluble contrast for confirmation
Pancreatitis	Pain in the epigastrium or lower chest that is often worse when lying flat and is relieved by leaning forward Vomiting Upper abdominal tenderness Shock Fever Often history of alcohol use disorder or biliary tract disease	Serum lipase (> 3 times upper limit of normal) Abdominal CT
Biliary tract disease	Recurrent right upper quadrant or epigastric discomfort following meals (but not exertion)	Ultrasonography of gallbladder Sometimes cholescintigraphy (hepatic iminodiacetic acid [HIDA] scan)
Esophageal motility disorders	Long-standing pain of insidious onset that may or may not accompany swallowing Usually also difficulty swallowing	Barium swallow Esophageal manometry
Esophageal reflux (GERD)	Recurrent burning pain radiating from epigastrium to throat that is exacerbated by bending down or lying down and relieved by antacids	Clinical evaluation Sometimes endoscopy Sometimes motility studies
Peptic ulcer	Recurrent, vague epigastric discomfort, particularly in a patient who smokes or uses alcohol excessively, that is relieved by food, antacids, or both No red flag findings (unless perforated or bleeding)‡	Clinical evaluation Sometimes endoscopy Sometimes testing for Helicobacter pylori
Pulmonary
Pulmonary embolism	Often pleuritic pain, dyspnea, tachycardia Sometimes mild fever, hemoptysis, shock More likely when risk factors are present	Risk stratification (Wells Criteria, Pulmonary Embolism Rule-out Criteria [PERC rule], Revised Geneva Scoring System) ECG, chest radiography, BNP, troponin (evaluate alternative diagnosis, and provide prognostic information) Sometimes POCUS (right ventricular size and function, interventricular septum, inferior vena cava) Sometimes D-dimer Sometimes CT pulmonary angiography
Tension pneumothorax	Significant dyspnea, hypotension, neck vein distention, unilateral diminished breath sounds and hyperresonance to percussion Sometimes subcutaneous air	Usually clinical evaluation Obvious on chest radiograph Sometimes immediate POCUS
Pneumonia	Fever, chills, cough, and sometimes purulent sputum Often dyspnea, tachycardia, signs of consolidation	Chest radiography
Pneumothorax	Sometimes, pleuritic chest pain, unilateral diminished breath sounds, and/or subcutaneous air	Chest radiography Sometimes POCUS or chest CT
Pleuritis	May have preceding pneumonia, pulmonary embolism, or viral respiratory infection Pain with breathing, cough Sometimes a pleural rub, but otherwise examination unremarkable	Usually clinical evaluation Sometimes chest radiography
Other
Various thoracic cancers	Variable but sometimes pleuritic pain Sometimes chronic cough, smoking history, signs of chronic illness (weight loss, fever), cervical lymphadenopathy	Chest radiography Chest CT if plain radiograph findings are compatible with cancer Bone scan considered for persistent, focal rib pain
Musculoskeletal chest wall pain (eg, due to trauma, overuse, or costochondritis)	Often suggested by history Pain typically persistent (typically days or longer), worsened with passive and active motion Diffuse or focal tenderness	Clinical evaluation
Fibromyalgia	Nearly constant pain, affecting multiple areas of the body as well as the chest Typically, fatigue and poor sleep Multiple trigger points	Clinical evaluation
Herpes zoster infection	Sharp, band-like pain in the thorax unilaterally Classic dermatomal, unilateral, vesicular rash Pain may precede rash by several days	Clinical evaluation
Idiopathic	Various features No red flag findings‡	Diagnosis of exclusion
* Seriousness of causes varies as indicated: ¹ Immediate life threats. ² Potential life threats. ³ Uncomfortable but usually not dangerous.
† Most patients with chest pain should have pulse oximetry, ECG, and chest radiography (basic tests). If there is suspicion of coronary ischemia, serum cardiac biomarkers (troponin, CK-MB) should also be checked.
‡ Red flag findings include abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension), signs of hypoperfusion (eg, confusion, ashen color, diaphoresis), shortness of breath, asymmetric breath sounds or pulses, new heart murmurs, or pulsus paradoxus > 10 mm Hg.
BNP = brain (B-type) natriuretic peptide; CK-MB = creatine kinase, MB fraction; ESR = erythrocyte sedimentation rate; POCUS = point-of-care ultrasound; S4 = fourth heart sound; TEE = transesophageal echocardiogram.

Cause*

Suggestive Findings

Diagnostic Approach†

Cardiovascular

Myocardial ischemia (acute myocardial infarction/unstable angina/ angina)

Acute, crushing pain radiating to the jaw or arm

Exertional pain relieved by rest (angina pectoris)

S4 gallop

Sometimes systolic murmurs of mitral regurgitation

Often red flag findings‡

Serial ECGs and cardiac biomarkers

Sometimes echocardiogram (traditional, POCUS, or both)

Stress imaging test or CT angiography considered in patients with negative or unchanged ECG findings and no cardiac biomarker elevation on serial testing

Often heart catheterization and coronary angiography if findings are positive

Thoracic aortic dissection

Sudden, tearing pain radiating to the back

Some patients have syncope, stroke, or leg ischemia

Pulse or blood pressure that may be unequal in extremities

Age > 55 years

Hypertension

Red flag findings‡

D-dimer in patients who are at low risk

Chest radiograph, which may reveal widening of the mediastinum

In patients who are hemodynamically stable: CT angiogram, possibly subsequent MR angiography or TEE

In patients who are hemodynamically unstable: bedside TEE

Myocarditis

Fever, dyspnea, fatigue, chest pain (if myopericarditis), recent viral or other infection

Sometimes findings of heart failure, pericarditis, or both

ECG

Serum cardiac biomarkers

ESR

C-reactive protein

Usually echocardiography or cardiac MRI

Pericarditis

Constant or intermittent sharp pain often aggravated by breathing, swallowing food, or supine position and relieved by sitting or leaning forward

Pericardial friction rub

Jugular venous distention (if constrictive pericarditis or large or rapidly accumulating pericardial effusion)

ECG

Serum cardiac biomarkers (sometimes showing minimal elevation of troponin and CK-MB levels if associated myocarditis present)

Transthoracic echocardiogram to evaluate for pericardial effusion

Gastrointestinal

Esophageal rupture

Sudden, severe pain following vomiting or instrumentation (eg, esophagogastroscopy or transesophageal echocardiography)

Subcutaneous crepitus detected during auscultation

Red flag findings‡

Chest radiography

Esophagography with water-soluble contrast for confirmation

Pancreatitis

Pain in the epigastrium or lower chest that is often worse when lying flat and is relieved by leaning forward

Vomiting

Upper abdominal tenderness

Shock

Fever

Often history of alcohol use disorder or biliary tract disease

Serum lipase (> 3 times upper limit of normal)

Abdominal CT

Biliary tract disease

Recurrent right upper quadrant or epigastric discomfort following meals (but not exertion)

Ultrasonography of gallbladder

Sometimes cholescintigraphy (hepatic iminodiacetic acid [HIDA] scan)

Esophageal motility disorders

Long-standing pain of insidious onset that may or may not accompany swallowing

Usually also difficulty swallowing

Barium swallow

Esophageal manometry

Esophageal reflux (GERD)

Recurrent burning pain radiating from epigastrium to throat that is exacerbated by bending down or lying down and relieved by antacids

Clinical evaluation

Sometimes endoscopy

Sometimes motility studies

Peptic ulcer

Recurrent, vague epigastric discomfort, particularly in a patient who smokes or uses alcohol excessively, that is relieved by food, antacids, or both

No red flag findings (unless perforated or bleeding)‡

Clinical evaluation

Sometimes endoscopy

Sometimes testing for Helicobacter pylori

Pulmonary

Pulmonary embolism

Often pleuritic pain, dyspnea, tachycardia

Sometimes mild fever, hemoptysis, shock

More likely when risk factors are present

Risk stratification (Wells Criteria, Pulmonary Embolism Rule-out Criteria [PERC rule], Revised Geneva Scoring System)

ECG, chest radiography, BNP, troponin (evaluate alternative diagnosis, and provide prognostic information)

Sometimes POCUS (right ventricular size and function, interventricular septum, inferior vena cava)

Sometimes D-dimer

Sometimes CT pulmonary angiography

Tension pneumothorax

Significant dyspnea, hypotension, neck vein distention, unilateral diminished breath sounds and hyperresonance to percussion

Sometimes subcutaneous air

Usually clinical evaluation

Obvious on chest radiograph

Sometimes immediate POCUS

Pneumonia

Fever, chills, cough, and sometimes purulent sputum

Often dyspnea, tachycardia, signs of consolidation

Chest radiography

Pneumothorax

Sometimes, pleuritic chest pain, unilateral diminished breath sounds, and/or subcutaneous air

Chest radiography

Sometimes POCUS or chest CT

Pleuritis

May have preceding pneumonia, pulmonary embolism, or viral respiratory infection

Pain with breathing, cough

Sometimes a pleural rub, but otherwise examination unremarkable

Usually clinical evaluation

Sometimes chest radiography

Other

Various thoracic cancers

Variable but sometimes pleuritic pain

Sometimes chronic cough, smoking history, signs of chronic illness (weight loss, fever), cervical lymphadenopathy

Chest radiography

Chest CT if plain radiograph findings are compatible with cancer

Bone scan considered for persistent, focal rib pain

Musculoskeletal chest wall pain (eg, due to trauma, overuse, or costochondritis)

Often suggested by history

Pain typically persistent (typically days or longer), worsened with passive and active motion

Diffuse or focal tenderness

Clinical evaluation

Fibromyalgia

Nearly constant pain, affecting multiple areas of the body as well as the chest

Typically, fatigue and poor sleep

Multiple trigger points

Clinical evaluation

Herpes zoster infection

Sharp, band-like pain in the thorax unilaterally

Classic dermatomal, unilateral, vesicular rash

Pain may precede rash by several days

Clinical evaluation

Idiopathic

Various features

No red flag findings‡

Diagnosis of exclusion

* Seriousness of causes varies as indicated:

¹ Immediate life threats.

² Potential life threats.

³ Uncomfortable but usually not dangerous.

† Most patients with chest pain should have pulse oximetry, ECG, and chest radiography (basic tests). If there is suspicion of coronary ischemia, serum cardiac biomarkers (troponin, CK-MB) should also be checked.

‡ Red flag findings include abnormal vital signs (tachycardia, bradycardia, tachypnea, hypotension), signs of hypoperfusion (eg, confusion, ashen color, diaphoresis), shortness of breath, asymmetric breath sounds or pulses, new heart murmurs, or pulsus paradoxus > 10 mm Hg.

BNP = brain (B-type) natriuretic peptide; CK-MB = creatine kinase, MB fraction; ESR = erythrocyte sedimentation rate; POCUS = point-of-care ultrasound; S4 = fourth heart sound; TEE = transesophageal echocardiogram.

In these topics

Chest Pain