One-liner#

Risk-stratify chest pain to identify ACS and other emergencies, then efficiently evaluate and manage the common outpatient causes (MSK, GERD, anxiety) without over-testing low-risk patients.

Key guidelines: 2021 ACC/AHA Chest Pain Guidelines | 2019 ESC Chronic Coronary Syndromes

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Ongoing chest pain with any: diaphoresis, radiation to arm/jaw/back, dyspnea, nausea, syncope
• ECG changes: ST elevation/depression, new LBBB, dynamic T-wave changes
• Hemodynamic instability: hypotension, tachycardia with poor perfusion
• High clinical suspicion for ACS regardless of ECG (diabetics, elderly, women may have atypical presentations)
• Sudden severe “tearing” pain radiating to back (aortic dissection)
• Pleuritic chest pain + dyspnea + tachycardia + risk factors (PE)
• Fever + pleuritic pain + hypoxia (pneumonia, empyema, pericarditis with effusion)

Key history#

Pain characteristics that increase ACS probability:

• Substernal pressure/squeezing (not sharp/stabbing)
• Radiation to left arm, jaw, neck, or back
• Associated dyspnea, diaphoresis, nausea
• Precipitated by exertion, relieved by rest
• Duration 10–30 minutes (not seconds, not hours)
• Prior CAD, PCI, CABG

Pain characteristics that decrease ACS probability:

• Sharp, stabbing, positional, pleuritic
• Reproducible with palpation
• Very brief (<30 seconds) or very prolonged (>24 hours continuous)
• Localized to small area (<3 cm)

Risk factors to document:

• Traditional CV risk: HTN, DM, dyslipidemia, smoking, family hx premature CAD (male <55, female <65)
• Prior cardiac history: MI, PCI, CABG, CHF, arrhythmia
• Cocaine/stimulant use (coronary vasospasm)
• Recent immobilization, surgery, travel, malignancy, estrogen use (VTE risk)

Special populations with atypical presentations:

• Women: More likely to present with fatigue, nausea, back/jaw pain rather than classic substernal pressure
• Elderly (>75): May present with dyspnea, confusion, or weakness rather than chest pain; higher baseline troponin
• Diabetics: Silent ischemia common due to autonomic neuropathy; lower threshold for workup

Associated symptoms:

• GI: heartburn, regurgitation, dysphagia, relief with antacids
• MSK: trauma, new activity, reproducible with movement/position
• Anxiety: situational triggers, hyperventilation, paresthesias, palpitations
• Pulmonary: cough, fever, dyspnea, hemoptysis

Focused exam#

• Vitals: BP both arms (>20 mmHg difference raises dissection concern), HR, RR, O2 sat
• General: diaphoresis, distress level, ability to speak in full sentences
• Cardiac: JVD, S3/S4, murmurs (new MR in ACS), rubs (pericarditis)
• Pulmonary: decreased breath sounds, crackles, wheezes
• Chest wall: reproducible tenderness (MSK), swelling, ecchymosis
• Extremities: unilateral leg swelling (DVT → PE), peripheral pulses
• Abdominal: epigastric tenderness (GERD/PUD), RUQ tenderness (biliary)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

In-office (if stable and low-intermediate risk):

• ECG: compare to prior if available; look for ST changes, T-wave inversions, Q waves, arrhythmia
• Point-of-care troponin (if available): useful for intermediate-risk patients; a single negative troponin does NOT rule out ACS—if you’re worried enough to check, the patient likely needs ED evaluation with serial troponins. POC troponin is most useful to confirm low risk in borderline cases, not to “clear” concerning presentations.

Risk stratification tools:

• HEART score (History, ECG, Age, Risk factors, Troponin): validated for chest pain risk stratification
  • 0–3: low risk (0.9–1.7% MACE); consider discharge with outpatient follow-up
  • 4–6: intermediate; observation, serial troponins, stress testing
  • ≥7: high risk; admission, cardiology consult

When to order stress testing:

• Stable patients with intermediate pretest probability of CAD (15-65% per ACC/AHA)
• Low-risk chest pain with negative serial troponins who need further risk stratification
• Known CAD with change in symptom pattern (after ruling out ACS)
• Optimal timing: Within 72 hours for intermediate-risk; within 2 weeks for low-risk outpatient evaluation
• Do not stress: unstable patients, recent ACS (<2 days), decompensated HF, severe AS, severe HTN (SBP >200)

When NOT to order stress testing:

• Very low pretest probability (<15%)—clinical reassurance is sufficient
• Very high pretest probability (>85%)—proceed directly to angiography
• Recent stress test (<2 years) with no change in symptoms
• Patient unable to achieve adequate workload AND no pharmacologic option available

Stress test selection:

• Exercise ECG: can exercise, interpretable baseline ECG, no prior revascularization
• Stress echo or nuclear: unable to exercise, uninterpretable ECG (LBBB, paced, LVH with repolarization changes, digoxin), prior PCI/CABG
• Pharmacologic stress: cannot exercise adequately

When NOT to do cardiac workup:

• Classic MSK pain (reproducible, positional, no risk factors, young)
• Classic GERD (postprandial, burning, relief with antacids, no risk factors)
• Low pretest probability + negative HEART score

Additional workup by suspected diagnosis:

• PE: Wells score → D-dimer (if low/intermediate) or CT-PA (if high)
• Pericarditis: ECG (diffuse ST elevation, PR depression), echo, inflammatory markers
• GERD: PPI trial; EGD if alarm features (dysphagia, weight loss, anemia, age >60 new onset)

Initial management#

• If ACS concern: ASA 325 mg (chewed) unless contraindicated; call 911 or direct to ED
• If stable, low risk: treat presumed diagnosis; ensure close follow-up; clear return precautions
• Document risk stratification: HEART score or clinical reasoning for not pursuing cardiac workup

Management by diagnosis#

Musculoskeletal chest pain (costochondritis, chest wall strain)#

Education:

• Chest wall pain is common and benign; not related to the heart
• May take 1–4 weeks to resolve; can recur with activity
• Heat, gentle stretching, and avoiding aggravating movements help

Treatment:

Follow-up: 2–4 weeks if not improving; sooner if new symptoms or concern for cardiac cause.

GERD / Esophageal chest pain#

Education:

• Acid reflux can cause chest pain that mimics heart pain
• Lifestyle changes are as important as medication: avoid late meals, elevate head of bed, weight loss, avoid triggers (alcohol, caffeine, fatty/spicy foods)
• Most patients improve within 2–4 weeks of treatment

Treatment:

Follow-up: 4–8 weeks; if no improvement, consider EGD. If improved, attempt step-down to H2RA or PRN PPI.

Stable angina#

Education:

• Angina means the heart muscle isn’t getting enough blood during exertion
• Medications reduce symptoms and cardiac risk; lifestyle changes are essential
• Know when to use sublingual NTG and when to call 911

Treatment:

Antianginal therapy:

Secondary prevention (all stable CAD patients):

If LDL remains >70 despite max statin:

• Add ezetimibe 10 mg daily ($ generic) → typically lowers LDL additional 15-20%
• If still above goal: consider PCSK9 inhibitor (evolocumab, alirocumab) via cardiology—$$$$, requires prior auth

Patients already on anticoagulation: If on warfarin or DOAC for AF/VTE, do NOT add aspirin routinely—bleeding risk often outweighs benefit. Discuss with cardiology; some high-risk post-PCI patients may need triple therapy short-term, but this is a specialist decision.

Referral urgency:

• Urgent (within 1 week): New-onset angina, worsening pattern, angina at low exertion levels, or angina with HF symptoms
• Routine (2–4 weeks): Stable symptoms on medical therapy needing stress test or optimization
• ED: Any unstable features (rest pain, crescendo pattern, associated dyspnea/diaphoresis)

Follow-up: Cardiology referral for stress testing and consideration of revascularization. PCP follow-up 4–6 weeks after medication optimization.

Pericarditis (acute, uncomplicated)#

Education:

• Inflammation of the sac around the heart, often post-viral
• Usually resolves in 1–2 weeks with treatment; recurrence is common (15–30%)
• Avoid strenuous activity until symptoms resolve and inflammatory markers normalize

Treatment:

Special situations:

• Post-MI pericarditis (Dressler syndrome): Use aspirin, NOT ibuprofen/NSAIDs—NSAIDs impair myocardial healing and increase risk of ventricular rupture
• On anticoagulation: Can continue anticoagulation in uncomplicated pericarditis; if large effusion or concern for hemorrhagic pericarditis, discuss with cardiology
• Recurrent pericarditis: Continue colchicine longer (6–12 months); may need cardiology referral for steroid-sparing agents

Follow-up: 1–2 weeks to assess response; echo if any concern for effusion or tamponade. Restrict exercise until asymptomatic and CRP normalized (typically 4–6 weeks).

Anxiety-related chest pain#

Education:

• Anxiety can cause real physical symptoms including chest pain, palpitations, and shortness of breath
• This is not “all in your head”—it’s a physiologic response, but it’s not dangerous
• Treatment is effective; avoiding triggers often makes anxiety worse

Treatment:

Acute management:

• Reassurance after appropriate cardiac risk stratification
• Breathing techniques (slow diaphragmatic breathing)
• Avoid caffeine, stimulants

If recurrent or GAD/panic disorder:

Follow-up: 2–4 weeks after starting medication; consider CBT referral. Avoid benzodiazepines for chronic anxiety.

Cocaine/stimulant-associated chest pain#

Recognition: Chest pain within hours of cocaine, methamphetamine, or other stimulant use. Can cause coronary vasospasm, ACS, aortic dissection, or arrhythmia even in young patients without traditional risk factors.

PCP role:

• If patient presents with active chest pain after recent stimulant use → ED immediately (cannot risk-stratify in office)
• If patient reports prior episodes or is seeking advice after the fact:
  • Counsel on cessation; offer addiction resources
  • Screen for underlying CAD if recurrent symptoms
  • Do NOT prescribe beta-blockers acutely (unopposed alpha stimulation can worsen vasospasm and hypertension)

Key points:

• Benzodiazepines are first-line in ED for cocaine chest pain (reduce sympathetic drive)
• Beta-blockers are contraindicated acutely; can use later if CAD confirmed and patient abstinent
• Troponin elevation is common even without true ACS; ED evaluation required

Follow-up: Addiction medicine or psychiatry referral; cardiology if CAD suspected.

Follow-up#

• Low-risk MSK/GERD: 2–4 weeks; sooner if not improving or new symptoms
• Intermediate risk with negative workup: 1–2 weeks; ensure stress test completed
• Stable angina: 4–6 weeks after medication optimization; coordinate with cardiology
• Pericarditis: 1–2 weeks; activity restriction until CRP normal

Return precautions (all patients):

• New or worsening chest pain
• Pain with exertion that wasn’t there before
• Shortness of breath, dizziness, or passing out
• Pain that doesn’t respond to prescribed treatment

Patient instructions#

• If you have chest pain with sweating, shortness of breath, or pain spreading to your arm or jaw, call 911 immediately.
• Take medications as prescribed; don’t stop heart medications without talking to your doctor.
• If you were given nitroglycerin: sit down, place one tablet under your tongue. If pain continues after 5 minutes, take a second. If still no relief after another 5 minutes, call 911.
• Avoid activities that trigger your symptoms until cleared by your doctor.
• Follow up as scheduled, even if you feel better.
• Bring a list of all your medications to every visit.

Smartphrase snippets#

• Chest pain, low risk: Atypical features (sharp, reproducible, positional), no cardiac risk factors, normal ECG. HEART score 0–3. Suspect MSK/GERD. No acute cardiac workup indicated. Discussed return precautions.

• Chest pain, intermediate risk: Some concerning features but stable. HEART score 4–6. Plan: stress test within 72 hours. Discussed return precautions including calling 911 for worsening pain, dyspnea, or diaphoresis.

• Stable angina, established CAD: Exertional chest pressure, relieved with rest, consistent with stable angina. On optimal medical therapy. No change from baseline. Continue current regimen. Follow up with cardiology.

• Acute pericarditis: Pleuritic chest pain, positional (worse supine, better leaning forward), recent viral illness. ECG shows diffuse ST elevation and PR depression. Started ibuprofen 600mg TID + colchicine 0.5mg BID. Activity restriction until asymptomatic and CRP normalized. Follow-up 1-2 weeks with repeat ECG and inflammatory markers.

Related pages#

Complaint pages#

• Palpitations — if arrhythmia suspected
• Syncope — if chest pain with LOC
• Dyspnea on exertion — cardiac vs pulmonary dyspnea
• Dyspnea (acute) — if acute shortness of breath
• Anxiety — if panic-related chest pain
• Dyspepsia/GERD — if GI-related chest pain
• Edema — if heart failure suspected

Problem pages (for ongoing management)#

• Coronary Artery Disease — stable angina, secondary prevention, antianginal therapy
• Heart Failure — HFrEF/HFpEF management, GDMT optimization, diuretic strategies
• Hypertension — BP management for CV risk reduction
• Hyperlipidemia — statin therapy, LDL targets, ASCVD risk reduction
• GERD — chronic acid reflux management, long-term PPI therapy, Barrett’s surveillance
• Generalized Anxiety Disorder — chronic anxiety management (coming soon)

Coding/billing notes#

• Document risk factors, HEART score (or equivalent reasoning), and rationale for workup decisions.
• If not ordering cardiac workup, document why (e.g., “classic MSK pattern with reproducible tenderness, no risk factors, HEART score 1”).
• For stable angina, document functional status and any change from baseline.