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Chest Pain Red Flags

Severe, Crushing Chest Pain

Severe, crushing chest pain, especially if radiating to the left arm, neck, or jaw, is a classic symptom of acute coronary syndrome (ACS), including myocardial infarction (MI).
Significance: This could indicate a myocardial infarction, requiring urgent hospitalisation and intervention.

Sudden Onset Chest Pain

Chest pain that starts suddenly and is severe may suggest a vascular emergency.
Significance: This could indicate aortic dissection or pulmonary embolism, both of which are life-threatening conditions requiring immediate assessment.

Pain Associated with Severe Shortness of Breath

Chest pain associated with severe shortness of breath raises concern for respiratory or cardiovascular emergencies.
Significance: This could signify pulmonary embolism, pneumothorax, or acute heart failure, all of which require urgent intervention.

Hypotension or Syncope

Hypotension (low blood pressure) or a history of fainting (syncope) in the context of chest pain suggests a haemodynamic compromise.
Significance: This could indicate conditions such as myocardial infarction, massive pulmonary embolism, or aortic dissection, which are medical emergencies requiring urgent evaluation.

Fever and Productive Cough

Fever with chest pain and a productive cough may indicate a serious infection like pneumonia.
Significance: This could signify bacterial pneumonia or empyema, which may lead to sepsis if untreated, requiring immediate antibiotic therapy and possibly hospitalisation.

Hemoptysis (Coughing up Blood)

Coughing up blood with chest pain is a worrying sign that can indicate serious lung pathology.
Significance: This could suggest pulmonary embolism, lung cancer, or tuberculosis, all of which are potentially life-threatening and require prompt diagnostic workup.

Neurological Deficit (e.g., Weakness, Numbness)

Chest pain associated with neurological deficits such as sudden weakness, numbness, or paralysis may suggest spinal cord involvement.
Significance: This could indicate spinal cord compression or aortic dissection with spinal involvement, both of which are surgical emergencies.

Unexplained Weight Loss

Significant and unexplained weight loss in the context of chest pain may raise suspicion for malignancy.
Significance: This could indicate lung cancer or oesophageal cancer, both requiring urgent diagnostic investigation, including imaging and biopsy.

Persistent Chest Pain with Dysphagia

Chest pain associated with difficulty swallowing (dysphagia) may suggest an underlying oesophageal disorder.
Significance: This could indicate oesophageal cancer, particularly if associated with weight loss or anaemia, necessitating urgent endoscopic evaluation.

Diagnostic Timeout

Chest Pain Investigations

Electrocardiogram (ECG)

A 12-lead ECG is the first-line investigation in almost all patients presenting with chest pain. It is critical for the immediate assessment of cardiac chest pain, particularly Acute Coronary Syndromes (ACS).
Relevance to DDx:
- Essential for rapidly identifying Myocardial Infarction (MI), specifically ST-segment elevation myocardial infarction (STEMI), requiring immediate reperfusion therapy.
- Can detect ischaemic changes (e.g., ST-depression, T-wave inversion) suggestive of Angina or non-ST-segment elevation myocardial infarction (NSTEMI), guiding further risk stratification and management.
- May reveal arrhythmias (e.g., atrial fibrillation, ventricular tachycardia) that could be exacerbating or contributing to chest pain, or be a consequence of underlying cardiac ischaemia or Pulmonary Embolism.
- Can show signs suggestive of Pericarditis (e.g., widespread ST elevation with PR depression), although less specific.
- A normal ECG, whilst reducing the likelihood of acute STEMI, does not exclude other serious causes of chest pain, including NSTEMI, unstable angina, PE, aortic dissection, or non-cardiac chest pain.
Result Significance:
- ST-segment elevation: Highly specific for acute STEMI, mandating immediate action.
- ST-depression or T-wave inversion: Suggestive of myocardial ischaemia (Angina or NSTEMI), requires further cardiac risk assessment and serial troponin measurements.
- New Left Bundle Branch Block (LBBB): In the context of chest pain, should be treated as a STEMI equivalent until proven otherwise.
- Arrhythmias: May require urgent management and further investigation to determine underlying cause.
- Normal ECG: Does not rule out significant cardiac pathology or other serious causes of chest pain; further investigations are often necessary based on clinical context.
Clinical Reasoning Tip: Always perform an ECG immediately in chest pain. While ECG is excellent for STEMI, remember its limitations in ruling out other ACS or non-cardiac serious conditions. Interpret ECG in conjunction with clinical context – history, examination, and risk factors. 'Time is myocardium' – act rapidly on STEMI findings.

High Sensitivity Troponin Assays

High sensitivity troponin assays are crucial blood tests used to detect myocardial injury. Serial measurements are essential for diagnosing and risk stratifying patients with suspected ACS.
Relevance to DDx:
- Elevated troponin levels are highly sensitive and specific for myocardial necrosis, confirming Myocardial Infarction (MI) (both STEMI and NSTEMI) when interpreted in the clinical context.
- May be elevated in other cardiac conditions such as Pericarditis, myocarditis, and heart failure, and non-cardiac conditions like Pulmonary Embolism, sepsis, renal failure and myocarditis. Clinical correlation is key.
- Serial troponin measurements (typically at presentation and 3-6 hours later, sometimes longer depending on assay and clinical scenario) are used to detect a rise and/or fall pattern indicative of acute myocardial injury in ACS.
- A normal troponin on presentation, especially with a low-risk ECG, makes acute MI less likely, but repeat testing is often needed, particularly if symptoms are ongoing or concerning for ACS. Very early presentations of MI may have normal initial troponin levels.
- In patients with non-cardiac chest pain (e.g., Musculoskeletal Chest Pain, GORD, Anxiety, Costochondritis, Medically Unexplained Chest Pain, Oesophageal Spasm, Rib Fracture, Herpes Zoster, Biliary Colic, Peptic Ulcer Disease, Lung Cancer, Oesophageal Cancer, Spinal Cord Compression, Pneumothorax, Pneumonia, COVID-19), troponin levels should ideally be negative to further support these diagnoses, though mild elevations can occur in non-cardiac conditions, especially in the presence of comorbidities like renal dysfunction.
Result Significance:
- Elevated and rising/falling troponin: Confirms myocardial injury, consistent with MI if clinically concordant. Guides management towards antiplatelet therapy, anticoagulation, and consideration of coronary angiography.
- Persistently elevated troponin (without rise/fall): May suggest chronic cardiac damage, myocarditis, or non-cardiac causes of troponin elevation (see above). Requires clinical correlation and consideration of other investigations (e.g. echocardiogram).
- Normal serial troponins: Significantly reduces the likelihood of acute MI, especially when combined with a normal ECG and low clinical risk. Further investigation and management guided by ongoing symptoms and risk factors.
Clinical Reasoning Tip: Troponin is essential for diagnosing MI, but interpret results in clinical context. Serial testing is crucial. Consider non-cardiac causes of troponin elevation. A single normal troponin, particularly very early after symptom onset, does not exclude MI. Use risk scores (e.g. HEART score) in conjunction with troponin and ECG results.

Full Blood Count (FBC) and C-Reactive Protein (CRP)

Full Blood Count (FBC) and C-Reactive Protein (CRP) are useful adjunct blood tests in the assessment of chest pain, particularly when infection or inflammatory conditions are considered.
Relevance to DDx:
- Leukocytosis (raised white cell count) on FBC and elevated CRP: Increases suspicion for Pneumonia or empyema as the cause of pleuritic chest pain, especially when combined with fever and productive cough. Can also be elevated in COVID-19.
- Anaemia (low haemoglobin) on FBC: Can exacerbate symptoms of Angina and may be relevant in cases of Oesophageal Cancer, Peptic Ulcer Disease or Lung Cancer if chronic blood loss is a factor. Anaemia itself is not a direct cause of acute chest pain but can contribute to myocardial ischaemia in patients with pre-existing CAD.
- FBC and CRP are typically normal in cardiac ischaemia (Angina, Myocardial Infarction), Pulmonary Embolism, Aortic Dissection, Pneumothorax, GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Anxiety, Pericarditis unless there is a co-existing infection or inflammatory process. However, CRP may be mildly elevated post-MI as an inflammatory marker but is not diagnostically helpful acutely for ACS itself.
- Thrombocytosis (raised platelet count) is non-specific but can be seen in inflammatory conditions or malignancy (e.g. Lung Cancer, Oesophageal Cancer).
Result Significance:
- Leukocytosis and elevated CRP: Supportive of an infectious or inflammatory process, particularly Pneumonia. Guides management towards further infection-focused investigations (e.g., chest X-ray) and antibiotic therapy.
- Anaemia: May require further investigation to determine the cause and consider implications for myocardial oxygen supply in patients with suspected cardiac chest pain.
- Normal FBC and CRP: Make infectious causes less likely but do not rule them out, and are typical in many other causes of chest pain including ACS, PE, aortic dissection, musculoskeletal causes etc.
Clinical Reasoning Tip: FBC and CRP are not first-line for cardiac chest pain, but valuable when infection or inflammation is in the differential. Leukocytosis and CRP raise suspicion for pneumonia; anaemia can worsen cardiac symptoms and prompt consideration of underlying malignancy in chronic chest pain. Normal FBC/CRP does not exclude serious non-inflammatory causes of chest pain.

D-dimer Assay

D-dimer is a fibrin degradation product used to assess the probability of venous thromboembolism, particularly Pulmonary Embolism (PE). It has high sensitivity but low specificity for PE.
Relevance to DDx:
- Elevated D-dimer: Increases the likelihood of Pulmonary Embolism, especially in patients with moderate or high pre-test probability (e.g., using Wells’ score or revised Geneva score). Necessitates further imaging with CT Pulmonary Angiography (CTPA) to confirm or exclude PE.
- A negative D-dimer result in *low* clinical probability patients effectively *rules out* Pulmonary Embolism, reducing the need for CTPA and radiation exposure. It is very useful for 'ruling out' PE in low risk patients.
- D-dimer can be falsely elevated in many non-PE conditions including infection (e.g., Pneumonia, COVID-19), malignancy (e.g., Lung Cancer, Oesophageal Cancer), inflammation (e.g. Pericarditis), recent surgery, trauma, pregnancy, and older age. Therefore, a positive D-dimer alone is not diagnostic of PE and must be interpreted cautiously in the clinical context.
- D-dimer is not typically relevant in the assessment of cardiac chest pain (Angina, Myocardial Infarction, Pericarditis), Aortic Dissection, Pneumothorax, GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Anxiety, Peptic Ulcer Disease unless PE is also suspected as a co-diagnosis or alternative.
Result Significance:
- Elevated D-dimer: Requires further investigation for PE, typically with CTPA, especially if clinical probability is moderate or high.
- Negative D-dimer in low probability patient: Effectively excludes PE, obviating need for CTPA. Clinical probability assessment is crucial to appropriate D-dimer use.
- False positive D-dimer: Common in many conditions; interpret positive results cautiously and always in clinical context.
Clinical Reasoning Tip: Use D-dimer strategically to rule out PE in *low-risk* chest pain patients. Always assess pre-test probability for PE (e.g., Wells score) before ordering D-dimer. A positive D-dimer requires CTPA to confirm PE. Remember D-dimer is not specific for PE and can be raised in many other conditions.

Chest Radiograph (CXR)

A Chest Radiograph (CXR) is a standard initial imaging modality for chest pain, particularly useful for evaluating pulmonary and some cardiac causes.
Relevance to DDx:
- Key investigation for identifying Pneumonia (consolidation), Pneumothorax (pleural air, collapsed lung), and pleural effusion.
- Can show signs of Heart Failure (e.g., cardiomegaly, pulmonary oedema, pleural effusions), which may be a consequence of Myocardial Infarction or other cardiac conditions.
- May detect bony abnormalities suggestive of Rib Fracture or Costochondritis (though CXR is not sensitive for costochondritis itself). Can also identify bony metastases from Lung Cancer or Oesophageal Cancer.
- CXR is typically normal in Angina, Myocardial Infarction (unless heart failure has developed), Pulmonary Embolism (usually, unless infarction has occurred), Aortic Dissection, Pericarditis, GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Anxiety, Peptic Ulcer Disease, COVID-19 (early or mild cases). A normal CXR does not exclude these diagnoses.
- CXR is also used in follow up of Lung Cancer to monitor for progression or complications.
Result Significance:
- Consolidation: Highly suggestive of pneumonia.
- Pleural air: Confirms pneumothorax.
- Cardiomegaly, pulmonary oedema, pleural effusions: Suggest heart failure.
- Rib fracture: Confirms traumatic or pathological fracture.
- Lung mass/nodule: Raises suspicion for lung cancer, requires further investigation (e.g., CT chest).
- Normal CXR: Does not exclude many serious causes of chest pain, particularly cardiac ischaemia, PE, aortic dissection. Further investigations are often needed.
Clinical Reasoning Tip: CXR is a valuable initial test for chest pain, especially for pulmonary pathology. It is good for pneumonia and pneumothorax. However, a normal CXR is common and does *not* rule out critical conditions like ACS or PE. Always consider further imaging if clinical suspicion remains high despite a normal CXR.

CT Pulmonary Angiography (CTPA)

CT Pulmonary Angiography (CTPA) is the definitive imaging modality for diagnosing Pulmonary Embolism (PE). It visualises the pulmonary arteries to detect thrombus.
Relevance to DDx:
- Confirms or excludes Pulmonary Embolism: CTPA is highly sensitive and specific for PE. It should be performed when PE is suspected based on clinical probability, D-dimer results, or concerning clinical features (e.g., acute dyspnoea, pleuritic chest pain, haemoptysis, risk factors for VTE).
- Can also detect alternative diagnoses or co-pathology such as Pneumonia, Pneumothorax, Lung Cancer or Aortic Dissection (although dedicated aortic CT is better for dissection).
- CTPA is not routinely indicated for cardiac chest pain (Angina, Myocardial Infarction, Pericarditis), GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Anxiety, Peptic Ulcer Disease, COVID-19 unless PE is also suspected.
Result Significance:
- Pulmonary embolus visualised: Confirms PE, guiding immediate anticoagulation therapy.
- No pulmonary embolus visualised: Effectively rules out PE as the cause of chest pain.
- Incidental findings: CTPA may reveal alternative diagnoses (e.g., pneumonia, lung mass) or co-existing conditions that explain the chest pain.
Clinical Reasoning Tip: CTPA is the gold standard for PE diagnosis. Use it when PE is clinically suspected, particularly if D-dimer is elevated or pre-test probability is moderate/high. Be mindful of radiation dose and consider V/Q scan as an alternative in specific patient groups (e.g. pregnancy, young patients with low CTPA risk). CTPA can also identify other lung pathology.

Echocardiography

Echocardiography (transthoracic echocardiogram, TTE) is an ultrasound scan of the heart, providing detailed information on cardiac structure and function. It is valuable in specific chest pain scenarios.
Relevance to DDx:
- Useful in evaluating patients with suspected Heart Failure, which can be a complication of Myocardial Infarction or other cardiac conditions. Can assess left ventricular function (ejection fraction), valvular abnormalities, and diastolic function.
- Can detect regional wall motion abnormalities suggestive of prior Myocardial Infarction or active ischaemia.
- Essential for diagnosing Pericarditis, by identifying pericardial effusion or features of constrictive pericarditis.
- Can assess for right ventricular strain, which may be present in Pulmonary Embolism (though not as sensitive or specific as CTPA for PE diagnosis).
- Echocardiography is not typically first-line for Angina, Aortic Dissection, Pneumothorax, Pneumonia, Lung Cancer, Oesophageal Cancer, Spinal Cord Compression, GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Anxiety, Peptic Ulcer Disease, COVID-19 unless there is a specific cardiac indication (e.g. suspected heart failure, valvular disease, pericarditis).
- Transoesophageal echocardiography (TOE) is more sensitive than TTE for detecting Aortic Dissection, but CT Angiography is often preferred as first-line due to wider availability and less invasiveness.
Result Significance:
- Reduced Ejection Fraction (EF): Confirms systolic heart failure.
- Regional wall motion abnormalities: Suggestive of myocardial ischaemia or prior MI.
- Pericardial effusion, thickened pericardium: Diagnostic of pericarditis or pericardial effusion.
- Right ventricular dilatation/dysfunction: May support diagnosis of PE but is not definitive.
- Valvular abnormalities: May explain heart failure or be relevant to chest pain in specific valvular conditions.
Clinical Reasoning Tip: Echocardiography is excellent for assessing cardiac function, heart failure, and pericardial disease in chest pain. Consider it especially if there are signs of heart failure, suspected pericarditis, or to assess for complications of MI. For suspected PE or aortic dissection, CTPA or CT Aortogram are usually more direct first-line imaging modalities.

Arterial Blood Gas (ABG)

Arterial Blood Gas (ABG) analysis assesses oxygenation, carbon dioxide levels, and acid-base balance in the blood. It is most useful in patients with chest pain and respiratory compromise or suspected metabolic disturbances.
Relevance to DDx:
- Hypoxaemia (low PaO2) is a key finding in Pulmonary Embolism, Pneumonia, Pneumothorax, COVID-19, and Acute Heart Failure (secondary to Myocardial Infarction or other causes) contributing to respiratory distress and chest pain. ABG quantifies the severity of hypoxaemia.
- Respiratory alkalosis (low PaCO2) can be seen in Pulmonary Embolism (due to hyperventilation) and Anxiety (hyperventilation syndrome).
- Acidosis (metabolic or respiratory) may indicate severe Pneumonia, sepsis, or cardiogenic shock (secondary to Myocardial Infarction), reflecting significant physiological derangement.
- ABG is not routinely indicated in uncomplicated Angina, Aortic Dissection, Pericarditis, GORD, Oesophageal Spasm, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Peptic Ulcer Disease, Lung Cancer, Oesophageal Cancer unless there is associated respiratory distress, hypoxia or concern for severe sepsis/shock.
Result Significance:
- Hypoxaemia: Objective evidence of respiratory compromise, common in PE, pneumonia, pneumothorax, heart failure, and severe COVID-19. Guides oxygen therapy and need for further respiratory support.
- Respiratory Alkalosis: May suggest PE or anxiety-related hyperventilation, needs clinical correlation.
- Acidosis: Indicates severe illness and potential for organ dysfunction. Requires urgent and comprehensive medical management.
- Normal ABG: Does not exclude serious conditions, especially if respiratory distress is not prominent, or in early/mild disease.
Clinical Reasoning Tip: Use ABG selectively in chest pain patients, primarily when there is respiratory distress, hypoxia, or suspicion of severe illness (e.g., sepsis, cardiogenic shock). ABG helps quantify respiratory and metabolic derangement and guide oxygen and ventilatory support, but is not a first-line diagnostic test for most causes of chest pain themselves.

Oesophagogastroduodenoscopy (OGD)

Oesophagogastroduodenoscopy (OGD) is an endoscopic procedure used to visualise the oesophagus, stomach, and duodenum. It is considered when upper gastrointestinal pathology is suspected as the cause of chest pain.
Relevance to DDx:
- OGD is indicated for persistent or atypical chest pain suggestive of Gastro-oesophageal Reflux Disease (GORD) unresponsive to medical therapy, to exclude oesophagitis, Barrett's oesophagus, or hiatus hernia.
- Used to diagnose Peptic Ulcer Disease (gastric or duodenal ulcers) if symptoms suggest PUD and initial management fails. Can also exclude gastric malignancy.
- Essential investigation for Oesophageal Cancer, particularly in patients with dysphagia, weight loss, or persistent chest pain not explained by other causes. Allows for tissue biopsy for histological diagnosis.
- Can diagnose Oesophageal Spasm by excluding other structural or mucosal abnormalities in patients with chest pain suspected to be of oesophageal origin. Manometry studies are the definitive test for oesophageal spasm itself, but OGD is often done first to rule out other pathology.
- OGD is not indicated for typical cardiac chest pain (Angina, Myocardial Infarction, Pericarditis), Pulmonary Embolism, Aortic Dissection, Pneumothorax, Pneumonia, Biliary Colic, Musculoskeletal Chest Pain, Costochondritis, Rib Fracture, Herpes Zoster, Medically Unexplained Chest Pain, Spinal Cord Compression, Anxiety, COVID-19 unless there are overlapping GI symptoms or diagnostic uncertainty.
Result Significance:
- Oesophagitis, hiatus hernia, Barrett's oesophagus: Support diagnosis of GORD and guide management.
- Gastric or duodenal ulcers: Confirm Peptic Ulcer Disease. Biopsy can exclude malignancy.
- Oesophageal malignancy: Definitive diagnosis of oesophageal cancer via biopsy. Stage and guide cancer treatment.
- Normal OGD: Reduces likelihood of significant oesophageal or gastroduodenal pathology as the cause of chest pain, but does not exclude functional oesophageal disorders like oesophageal spasm.
Clinical Reasoning Tip: OGD is a specialist investigation for chest pain when gastrointestinal causes are strongly suspected, particularly GORD, PUD, or oesophageal cancer. Reserve OGD for cases where initial management of GORD fails, or when red flag symptoms for upper GI malignancy are present (dysphagia, weight loss, anaemia). It is not a routine test for chest pain and should be guided by GI symptom profile.

Chest Pain Evidence-Based Diagnosis

Severe, Crushing Chest Pain suggesting Myocardial Infarction

Severe, crushing, central chest pain, often radiating to the left arm, jaw or neck, potentially accompanied by sweating (diaphoresis), nausea, or shortness of breath.
Evidence: Classic cardiac pain features increase likelihood of ACS; studies report Positive Likelihood Ratios (LR+) generally ranging from ~2 to 7 for features like radiation to arms/shoulders. Positive Predictive Value (PPV) varies widely by clinical setting (estimated ~5-15% in primary care, higher in ED).
Reference: Body R et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281-6. and NICE Guideline NG185: Acute coronary syndromes (2020).
Significance: History suggestive of cardiac pain significantly increases the probability of Myocardial Infarction (MI) or unstable Angina (collectively Acute Coronary Syndrome - ACS). Requires immediate cardiac workup (ECG, Troponin), especially in patients with risk factors. However, sensitivity is limited; atypical presentations (e.g., epigastric pain, isolated dyspnoea) are common, particularly in women, elderly individuals, and those with diabetes.
Clinical Reasoning Tip: Prioritise ruling out ACS in patients describing typical cardiac pain features. Use these features to raise suspicion but do not rely on them to rule out ACS, especially in high-risk or atypical groups. Combine history with ECG, troponin, and risk stratification scores (e.g., HEART).

Pleuritic Chest Pain suggesting Pulmonary Embolism or Pneumonia

Sharp, stabbing chest pain, worsened by inspiration or coughing.
Evidence: While included in clinical prediction rules (e.g., Wells'), evidence indicates pleuritic pain has modest diagnostic value in isolation for PE (Positive Likelihood Ratio often < 2). Guidelines note its frequent association with pulmonary/pleural conditions like Pneumonia.
Reference: NICE Guideline NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2020). and NICE Clinical Guideline CG191: Pneumonia in adults: diagnosis and management (2014).
Significance: Pleuritic chest pain increases the probability of pulmonary or pleural causes like Pulmonary Embolism (PE), Pneumonia, Pleurisy, Pericarditis, Pneumothorax, and can occur with Costochondritis. It makes typical cardiac ischaemia less likely but doesn't exclude it. Not sensitive or specific enough for diagnosis alone.
Clinical Reasoning Tip: Pleuritic chest pain prompts consideration of pulmonary/pleural causes. Combine this feature with risk factors (for PE), associated symptoms (fever/cough for Pneumonia), and relevant investigations (D-dimer, CXR, CTPA) to guide diagnosis.

Chest Wall Tenderness suggesting Musculoskeletal Chest Pain

Chest pain reproducible by palpation of the chest wall muscles, ribs, or costochondral junctions.
Evidence: Studies consistently show reproducible chest wall tenderness has high specificity (often reported as >85%) for supporting a musculoskeletal diagnosis, though sensitivity is lower and more variable (reported range ~20% to 75%).
Reference: Verdon F et al. Chest wall syndrome: a common cause of chest pain. Prim Care Companion J Clin Psychiatry. 2007;9(5):391-3. and Ayloo A et al. Diagnosis and management of musculoskeletal chest pain. Am Fam Physician. 2013;88(11):757-62.
Significance: High specificity means its presence strongly supports a musculoskeletal diagnosis. However, low sensitivity means its absence does not rule it out. Importantly, musculoskeletal tenderness can occasionally co-exist with serious pathology (e.g., ACS).
Clinical Reasoning Tip: Routinely palpate the chest wall. Reproducible tenderness strongly suggests a musculoskeletal cause, but *always* consider and exclude serious underlying conditions (like ACS) based on the overall clinical picture before attributing pain solely to this finding.

Heartburn and Acid Regurgitation suggesting GORD

Retrosternal burning pain ('heartburn'), often worse after meals, spicy food, alcohol, or lying flat, possibly relieved by antacids, and often associated with acid regurgitation into the mouth.
Evidence: Symptom-based diagnosis using typical features has moderate accuracy for GORD (Sensitivity often ~60-70%, Specificity ~70-80%), according to consensus definitions. Diagnostic confidence increases significantly with a positive response to a PPI trial, as recommended by NICE guidance.
Reference: Vakil N et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-20. and NICE Clinical Knowledge Summary (CKS): Dyspepsia - proven GORD (Updated Jan 2023).
Significance: Typical symptoms significantly increase the probability of Gastro-oesophageal Reflux Disease (GORD). Atypical chest pain presentations of GORD are common and harder to distinguish from cardiac pain. Consider GORD especially if symptoms are chronic, meal-related, postural, or respond to antacids/PPIs.
Clinical Reasoning Tip: Thoroughly explore symptoms for typical GORD features. An empirical trial of PPI therapy can be both diagnostic and therapeutic in suspected cases *after* serious cardiac causes have been reasonably excluded based on risk assessment, ECG, and potentially troponins. Beware the 'cardiac masquerade'.

Anxiety Symptoms suggesting Panic Disorder as cause of Chest Pain

Episodic chest pain occurring during a discrete period of intense fear or discomfort, accompanied by characteristic panic symptoms (e.g., palpitations, sweating, trembling, shortness of breath, choking feeling, dizziness, derealisation, fear of dying/losing control).
Evidence: While criteria (e.g., DSM-5) accurately diagnose Panic Disorder itself, attributing chest pain solely to panic requires excluding organic causes. Studies indicate Panic Disorder is present in a significant proportion (estimated ~20-40%) of patients presenting with non-cardiac chest pain.
Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision (DSM-5-TR). 2022. and NICE Clinical Guideline CG113: Generalised anxiety disorder and panic disorder in adults: management (2011, updated 2019).
Significance: Co-existing panic attack symptoms increase the likelihood that Anxiety/Panic Disorder is contributing to or is the primary cause of the chest pain episode, *once life-threatening organic causes have been excluded*.
Clinical Reasoning Tip: Consider anxiety/panic in the differential, especially with typical panic features during episodes and known history. However, it remains a diagnosis of exclusion for the chest pain itself. Use validated screening tools (e.g., GAD-7, PHQ-9 for co-morbidity) and address anxiety, but ensure cardiac/pulmonary causes are ruled out first according to risk stratification.

Reduced Oxygen Saturation (SpO2 <95% on room air) suggesting Pulmonary Pathology

Oxygen saturation measured by pulse oximetry persistently below 95% (or below patient's baseline if known chronic lung disease) breathing room air.
Evidence: Guidelines (e.g., BTS) define hypoxaemia thresholds (typically <94-95%) as indicating significant cardiorespiratory compromise and illness severity. While sensitivity for severe conditions like major PE or pneumonia can be moderate (~50-80%), specificity is low as it reflects physiological state, not a specific diagnosis.
Reference: British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings (2017). and Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA. 2018;319(6):559-566. (Notes SpO2 threshold in PERC rule).
Significance: Hypoxaemia strongly suggests significant underlying pathology affecting gas exchange, increasing the probability of Pulmonary Embolism, Pneumonia, Pneumothorax, COVID-19, or severe Acute Heart Failure (e.g., post-MI pulmonary oedema). It's a marker of severity requiring urgent investigation and potential oxygen therapy. Normal SpO2 *does not* exclude these conditions, particularly smaller PEs or early pneumonia.
Clinical Reasoning Tip: Measure SpO2 routinely. Hypoxaemia (<95% or drop from baseline) is a crucial red flag indicating significant illness. Prioritise investigations for pulmonary and severe cardiac causes. Remember normal SpO2 doesn't rule out serious pathology.

Elevated Troponin Levels confirming Myocardial Infarction

Elevated cardiac troponin level (high-sensitivity assay preferred) above the 99th percentile upper reference limit, ideally with a significant rise and/or fall pattern on serial testing, consistent with the clinical picture.
Evidence: Guidelines (e.g., NICE, ESC) state high-sensitivity troponin assays, used with validated serial testing algorithms (e.g., 0/1h or 0/3h), achieve very high sensitivity (often >95%) and Negative Predictive Value (>99%) for ruling out MI. Specificity is lower (~80-90%) due to other causes of myocardial injury.
Reference: NICE Guideline NG185: Acute coronary syndromes (2020). and Thygesen K, et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-2264.
Significance: A dynamic change (rise/fall) in hs-cTn above the 99th percentile confirms acute myocardial injury and, in the context of ischaemic symptoms/signs, defines Myocardial Infarction (MI). Guides urgent ACS management pathway. Persistently elevated levels without dynamic change suggest chronic injury or non-ACS causes (e.g., heart failure, PE, sepsis, renal failure, myocarditis).
Clinical Reasoning Tip: Use hs-cTn assays and guideline-recommended serial testing algorithms (e.g., NICE 0/1h or 0/3h pathways) for rapid rule-in/rule-out of MI. Very high NPV allows safe discharge for low-risk patients with negative serial results. Always interpret troponin levels in the clinical context (history, ECG, risk factors) and consider non-ACS causes for elevations without a clear dynamic change or ischaemic picture.

ST-Segment Elevation on ECG confirming STEMI

New ST-segment elevation at the J-point in ≥2 contiguous leads meeting voltage criteria (e.g., ≥1mm in limb leads, ≥2mm in V2-V3 [adjusted for age/sex], ≥1.5mm in women in V2-V3), or new LBBB assumed to be ischaemic.
Evidence: Guidelines confirm ST-segment elevation meeting criteria has high specificity (>90%) but moderate sensitivity (~45-55%) for identifying acute coronary occlusion causing STEMI, as many MIs are NSTEMI.
Reference: Collet JP et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. (Defines STEMI criteria) and NICE Guideline NG185: Acute coronary syndromes (2020).
Significance: ST-elevation fulfilling criteria is diagnostic of STEMI, indicating acute, ongoing transmural myocardial injury typically due to complete coronary artery occlusion. Requires immediate reperfusion therapy (Primary PCI preferred in UK, or thrombolysis if unavailable promptly).
Clinical Reasoning Tip: Recognise STEMI criteria instantly. This is a time-critical emergency requiring immediate activation of the local reperfusion pathway (e.g., direct call to cath lab). Be aware of STEMI equivalents (new LBBB, posterior MI signs) and evolving changes (hyperacute T waves).

Elevated D-dimer with appropriate Clinical Probability for Pulmonary Embolism

Elevated D-dimer level (using an age-adjusted threshold where appropriate) in a patient assessed to have a low or moderate pre-test probability of Pulmonary Embolism (PE) using a validated score (e.g., Wells', revised Geneva). Not typically used if pre-test probability is high.
Evidence: Guidelines confirm D-dimer testing has high sensitivity (often >95%) but low specificity (highly variable, ~40-60%) for PE. Its key value lies in the very high Negative Predictive Value (>99%) when combined with a low clinical pre-test probability, allowing safe rule-out.
Reference: NICE Guideline NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2020). and Konstantinides SV et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603.
Significance: A *negative* D-dimer in a patient deemed low clinical risk effectively excludes Pulmonary Embolism (PE). An *elevated* D-dimer does *not* confirm PE due to low specificity (many other causes) but mandates further investigation (usually CTPA) if clinical suspicion persists (i.e., in moderate/high risk groups or if low risk assessment was borderline).
Clinical Reasoning Tip: Use D-dimer testing *selectively* as part of a PE diagnostic algorithm, incorporating pre-test probability assessment (e.g., Wells' score or clinician gestalt guided by PERC rule criteria if applicable). Primarily used to *rule out* PE in low-risk patients to avoid unnecessary imaging. Do not use D-dimer if clinical probability is high (proceed direct to imaging). Remember age-adjustment improves specificity in older adults.

Consolidation on Chest X-ray confirming Pneumonia

Opacification (consolidation) on chest radiograph consistent with alveolar filling, often lobar or segmental, in a patient with clinical features of lower respiratory tract infection (e.g., cough, fever, purulent sputum, pleuritic pain, focal chest signs).
Evidence: Evidence synthesis suggests Chest X-ray has moderate sensitivity (estimated range ~70-80%) and higher specificity (range ~85-95%) for diagnosing typical bacterial Pneumonia presenting as consolidation, compared to clinical assessment alone.
Reference: NICE Clinical Guideline CG191: Pneumonia in adults: diagnosis and management (2014). and Metlay JP et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.
Significance: The presence of new consolidation on CXR strongly supports the diagnosis of Pneumonia in the right clinical context, guiding antibiotic choice and severity assessment (e.g., using CURB-65 score). A normal CXR makes typical bacterial pneumonia less likely but doesn't exclude it entirely, nor does it exclude other causes of the patient's symptoms.
Clinical Reasoning Tip: Obtain a CXR in patients with suspected pneumonia (clinical signs + systemic features). Consolidation confirms the diagnosis. Interpret CXR findings alongside clinical features and inflammatory markers (CRP). Consider alternative diagnoses or further imaging (CT) if CXR is negative but clinical suspicion remains high, or if complications are suspected.

HPC ICE

Chest Pain History

Patient’s Description: Start with truly open questions.

Start by asking: "How can I help you today?" or "What brings you in to see me today?"
- These are the most effective initial questions, especially when you are unsure of the patient's primary concern.
Once the patient mentions "chest pain" (or related terms like "discomfort in my chest", "tightness", etc.) as their concern, acknowledge it and then gently guide them to elaborate:
- Follow-up after patient mentions chest complaint: "Okay, you're having chest pain. Can you tell me more about that?" or "Right, chest pain. Please describe what you're experiencing."
This two-step approach is crucial:
- Truly Open Start: "How can I help you?" is completely open and patient-centred. It allows the patient to present their *real* agenda, which might not be exactly what we expect. They may have multiple concerns, or 'chest pain' may be their term for something else.
- Avoids Assumptions: We don't presume we know why they are there.
- Natural Conversation Flow: After they mention chest pain, the follow-up questions naturally guide the conversation to the specific symptom we are interested in, without being abrupt or leading from the start.
- Encourages Patient Narrative: By first asking "Tell me more about that" or "Describe what you're experiencing," we still encourage the patient to use their own words to describe the chest pain itself.
Active listening remains essential. Let the patient speak without interruption in both the initial open phase and when describing the chest pain specifically.
- This revised approach starts with genuine open-endedness and then smoothly transitions to a focused exploration of chest pain, once the patient has identified it as a concern.
Relevance: This refined opening respects the patient's agenda, ensures you don't miss the real presenting problem, and then effectively guides the history taking towards a detailed understanding of their chest pain, ensuring a truly patient-centred and diagnostically sound consultation from the very first question.

Quality of Pain: Can you describe what the pain feels like?

The description of pain quality (e.g., sharp, dull, burning, crushing) can provide critical diagnostic insights.
Relevance:
- Cardiac Chest Pain (Angina, Myocardial Infarction): Often described as crushing, squeezing, tightness, pressure, or heavy weight. May be difficult to describe as 'pain' at all.
- Pericarditis, Pleurisy, Pneumonia & Pulmonary Embolism: Sharp or pleuritic pain, often worsened by breathing or coughing.
- Musculoskeletal Chest Pain & Costochondritis: Aching, sore, or sharp pain, often reproducible on palpation.
- GORD & Oesophageal Spasm: Burning or tight pain, potentially mimicking cardiac pain, often related to meals or acid reflux.
- Anxiety & Medically Unexplained Chest Pain: Variable descriptions, may be vague, fleeting or inconsistent.
Clinical Reasoning Tip: Think 'crushing/squeezing' for cardiac emergencies, 'sharp/pleuritic' for pulmonary/pleural causes, and 'aching/sore' for musculoskeletal issues. Consider GORD or anxiety if descriptions are atypical or burning.

Location and Radiation: Where exactly is the pain, and does it spread anywhere else?

Asking about pain location and whether it radiates can narrow the differential diagnosis.
Relevance:
- Myocardial Ischaemia (Angina, Myocardial Infarction) & Aortic Dissection: Pain often located centrally or across the chest. Radiation to the left arm, jaw, neck, or back is classic for cardiac pain. Aortic dissection may radiate to the back between the shoulder blades.
- Pulmonary Embolism & Pneumonia & Pleurisy & Pericarditis: Can be more localised, but less specific radiation patterns than cardiac pain. Pleuritic pain often localised to the affected area of pleura.
- Musculoskeletal Chest Pain & Costochondritis & Herpes Zoster: Usually localised to the chest wall. Herpes Zoster follows a dermatomal distribution (often band-like).
- GORD & Oesophageal Spasm: Often retrosternal (behind the breastbone), may radiate upwards towards the throat.
Clinical Reasoning Tip: Central chest pain with left arm/jaw radiation is concerning for cardiac ischaemia. Back radiation should raise suspicion for aortic dissection. Localised pain points towards musculoskeletal or dermatological causes.

Onset and Duration: When did the pain start, and how long does it last?

Clarifying the onset (sudden or gradual) and duration of the chest pain is essential for diagnosis.
Relevance:
- Acute, Sudden Onset Pain (Myocardial Infarction, Pulmonary Embolism, Aortic Dissection, Pneumothorax): Suggests acute, potentially life-threatening conditions. Sudden, severe pain with collapse is a major red flag.
- Angina: Typically episodic, lasting minutes (often 2-10 minutes), brought on by exertion and relieved by rest or nitrates.
- Musculoskeletal Chest Pain & Costochondritis & Anxiety: Variable onset, may be gradual or related to specific events (e.g., injury, stress). Duration can be variable, from hours to days.
- GORD & Oesophageal Spasm: Episodic, duration can vary from minutes to hours, often related to meals or posture.
- Pain lasting seconds: Rarely cardiac in origin and has a high negative predictive value for cardiac chest pain.
Clinical Reasoning Tip: Sudden, severe onset is a red flag for critical conditions. Brief, fleeting pain is less likely to be serious. Angina is typically exertional and of limited duration.

Triggers and Exacerbating/Relieving Factors: Is there anything that makes the pain better or worse?

Understanding what triggers or relieves the pain is crucial.
Relevance:
- Angina: Classically worsened by exertion (exercise, emotional stress, cold weather) and relieved by rest or nitroglycerin. Exertional chest pain relieved by rest has a significantly higher positive likelihood ratio for angina.
- Musculoskeletal Chest Pain & Costochondritis & Rib Fracture: Worsened by movement, palpation, deep breathing, coughing, or specific postures.
- Pericarditis & Pleurisy & Pneumonia & Pulmonary Embolism & Pneumothorax: Worsened by breathing deeply or coughing (pleuritic component). Pericarditis may be relieved by sitting forward.
- GORD & Oesophageal Spasm: May be worsened by food (especially fatty or spicy foods), alcohol, lying down, and relieved by antacids, sitting up, or drinking water.
- Anxiety: Triggers may be stress, panic-inducing situations. Relief may be with relaxation techniques, anxiolytics, but is often variable and less predictable.
Clinical Reasoning Tip: Exertional pain relieved by rest is highly suggestive of angina. Pain worsened by palpation points to musculoskeletal causes. Food-related pain suggests GORD or oesophageal issues.

Associated Symptoms: Have you noticed any other symptoms like shortness of breath, palpitations, fever, or a rash?

Exploring associated symptoms is vital.
Relevance:
- Shortness of Breath (Dyspnoea): Suggests serious conditions such as Pulmonary Embolism, Pneumonia, Pneumothorax, Myocardial Infarction, Angina, Pericarditis. Also seen in anxiety, but often less severe and with hyperventilation symptoms.
- Palpitations: Can occur with Angina, Anxiety, and Pericarditis, but also in arrhythmias unrelated to chest pain.
- Fever and Cough: Strongly suggest Pneumonia or other infections like COVID-19.
- Rash (especially vesicular, dermatomal): Highly suggestive of Herpes Zoster.
- Diaphoresis (Sweating), Nausea, Vomiting, Lightheadedness, Syncope (Fainting): Commonly associated with Myocardial Infarction & Pulmonary Embolism, reflecting autonomic nervous system activation and haemodynamic compromise.
- Leg Swelling or Pain: Increases risk for Pulmonary Embolism, suggesting Deep Vein Thrombosis (DVT).
Clinical Reasoning Tip: Shortness of breath with chest pain is a red flag. Fever points to infection. Rash suggests herpes zoster. Sweating, nausea, and lightheadedness are worrisome for cardiac or pulmonary embolism.

Past Medical History (PMH): Have you had any previous heart, lung, or gastrointestinal problems?

A patient’s past medical history is often key to risk stratification.
Relevance:
- Coronary Artery Disease (CAD), Previous Myocardial Infarction (MI), Angina: Dramatically increases the likelihood of recurrent Angina or Myocardial Infarction.
- Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE): Raises suspicion for recurrent Pulmonary Embolism.
- Asthma, COPD, Pneumonia: Increases risk of Pneumonia & Pneumothorax.
- Gastro-oesophageal Reflux Disease (GORD) or Hiatus Hernia: Suggests possible GORD as cause of chest pain.
- Cancer History (Lung, Oesophageal, Breast, etc.): Raises suspicion for Lung Cancer, Oesophageal Cancer, or metastatic disease if chest pain is new or persistent.
- Anxiety or Panic Disorder: Consider Anxiety as a cause, especially if past episodes are similar.
Clinical Reasoning Tip: Prior cardiac history is the strongest risk factor for cardiac chest pain. Previous VTE/PE increases risk of recurrent PE. Consider past respiratory conditions for pulmonary causes.

Family History (FH): Does anyone in your family have heart disease, blood clots, or cancer?

Family history can reveal predispositions to certain conditions.
Relevance:
- Early-onset Coronary Artery Disease (CAD) or Myocardial Infarction (MI) in first-degree relatives: Increases risk of Angina and Myocardial Infarction, especially in younger patients.
- Venous Thromboembolism (VTE), Hypercoagulable States: Raises risk for Pulmonary Embolism.
- Lung Cancer, Oesophageal Cancer, or other cancers: May suggest increased risk for Lung Cancer or Oesophageal Cancer, though less directly linked to acute chest pain unless metastatic disease is suspected.
- Hypertrophic Cardiomyopathy, Long QT Syndrome, or other inherited cardiac conditions: May predispose to Angina or cardiac causes, particularly in younger individuals with exertional symptoms or palpitations.
Clinical Reasoning Tip: Family history of early heart disease or blood clots increases risk for cardiac and pulmonary embolism. Family history of cancer can be relevant for lung or oesophageal cancer in persistent chest pain.

Drug History: Are you taking any regular medications, or have you recently started any new medications?

Certain medications can cause chest pain or influence underlying conditions.
Relevance:
- Beta-blockers: May mask tachycardia in Pulmonary Embolism or other conditions, potentially blunting typical vital sign responses.
- Anticoagulants: May increase the risk of bleeding complications if Aortic Dissection or other bleeding-prone conditions are present.
- Non-steroidal Anti-inflammatory Drugs (NSAIDs): Can exacerbate GORD, and some have been linked to increased cardiovascular risk.
- New Medications: Consider drug-induced oesophagitis (e.g., bisphosphonates, some antibiotics), drug-induced angina (rare), or side effects mimicking chest pain.
- Medications for GORD: If patient is already on PPIs or antacids, and chest pain persists, GORD is less likely as the primary cause, but does not rule it out.
Clinical Reasoning Tip: Be aware of medications that can mask symptoms (beta-blockers) or increase risks (anticoagulants). Consider drug side effects as a less common cause of chest pain.

Social History: Do you smoke or drink alcohol, and what do you do for work?

Smoking and alcohol use are significant risk factors for various conditions. Occupational hazards may also be relevant.
Relevance:
- Smoking: Major risk factor for Coronary Artery Disease (Angina, Myocardial Infarction), Lung Cancer, and Oesophageal Cancer, and contributes to GORD and COPD (increasing risk of pneumonia/pneumothorax).
- Excessive Alcohol Use: Risk factor for GORD, oesophageal cancer, and cardiomyopathy (though less directly linked to acute chest pain).
- Recreational Drug Use (especially stimulants like cocaine/amphetamines): Can cause chest pain due to coronary artery vasospasm, myocardial infarction, or contribute to aortic dissection risk. Important to consider, particularly in younger patients presenting with acute chest pain.
- Occupation:
  - Sedentary Jobs: May increase risk of VTE/Pulmonary Embolism.
  - Jobs with Asbestos Exposure (e.g., construction, shipbuilding): Increases risk of lung diseases including lung cancer.
  - Jobs with Repetitive Lifting or Strain: May contribute to musculoskeletal chest pain or rib injuries.
Clinical Reasoning Tip: Smoking is a critical risk factor across many serious chest pain conditions. Consider occupational exposures for lung and musculoskeletal issues.

Ideas, Concerns, and Expectations (ICE)

ICE questions help to explore the patient’s perspective and ensure patient-centred care.
Relevance:
- Understanding patient's **Ideas** about the cause can reveal pre-conceived notions or anxieties that influence their presentation and management.
- Exploring **Concerns** ("Is there something specific you are worried about?") directly addresses patient anxieties, especially about serious conditions like heart attack or cancer (Myocardial Infarction, Lung Cancer).
- Understanding **Expectations** ("What were you hoping we might be able to do for you today?") helps align management with patient goals and facilitates shared decision-making. Some patients may primarily seek reassurance, while others need definitive diagnosis and treatment.
Clinical Reasoning Tip: ICE is crucial for patient-centred care. Addressing patient concerns, especially about serious conditions, is paramount, even when considering benign diagnoses. Align expectations for realistic and shared management.

Chest Pain Examination

General Inspection: Inspect the patient for general signs of distress, pallor, or sweating

Observation of the patient's general appearance can give important clues about the severity of the condition.
Relevance:
- Distress, Pallor, Diaphoresis (Sweating): Red flags suggesting serious underlying pathology. Strongly associated with Myocardial Infarction, Pulmonary Embolism, and Aortic Dissection. Also seen in severe Pneumothorax and Pneumonia.
- Anxious Appearance, Hyperventilation: May be seen in Anxiety related chest pain, but it's crucial to exclude serious causes *first*.
- Well appearing, comfortable: Makes acute, life-threatening emergencies less likely, but does not rule them out, especially in early stages of conditions like angina or early pulmonary embolism.
Clinical Reasoning Tip: Patient appearance provides a rapid initial risk stratification. Distress, pallor, and sweating are red flags requiring urgent attention to exclude "Must Not Miss" conditions.

Vital Signs: Measure blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature

Vital signs are critical in assessing the stability of the patient and guiding the differential diagnosis.
Relevance:
- Hypotension (Low Blood Pressure): Red flag. Suggests haemodynamic compromise seen in Myocardial Infarction, Pulmonary Embolism, Aortic Dissection, Tension Pneumothorax, and severe Sepsis/Pneumonia.
- Tachycardia (Fast Heart Rate): Non-specific but common in many chest pain conditions including Myocardial Infarction, Pulmonary Embolism, Pneumonia, Pericarditis, Anxiety. May be blunted by beta-blockers (consider drug history).
- Bradycardia (Slow Heart Rate): Less common in acute chest pain, but consider in inferior Myocardial Infarction or medication effects.
- Tachypnoea (Fast Respiratory Rate) & Hypoxia (Low Oxygen Saturation): Suggests respiratory or pulmonary pathology like Pulmonary Embolism, Pneumonia, Pneumothorax, Pulmonary Oedema. Hypoxia is a red flag.
- Fever: Raises suspicion for infectious causes such as Pneumonia, Pericarditis, or rarely, pleurisy if infectious aetiology suspected. Less likely in cardiac ischaemia unless complications present.
- Normal Vital Signs: Helpful in making acute emergencies less likely, but do *not* rule out serious conditions, particularly early Myocardial Infarction or Pulmonary Embolism. Vital signs can be initially normal in these conditions.
Clinical Reasoning Tip: Abnormal vital signs, especially hypotension or hypoxia, are red flags. While normal vital signs are reassuring, they don't exclude serious diagnoses, so interpret them in context of the history.

Jugular Venous Pressure (JVP) Assessment: Evaluate the jugular venous pressure for signs of fluid overload or heart failure

Raised JVP is a key sign of right heart failure or pulmonary embolism.
Relevance:
- Elevated JVP: Suggests right ventricular strain or failure, seen in:
  - Pulmonary Embolism (massive PE causing acute right heart strain)
  - Right Ventricular Myocardial Infarction (inferior MI extending to right ventricle)
  - Congestive Heart Failure (less specific to acute chest pain unless acute decompensation)
  - Tension Pneumothorax (due to mediastinal shift impeding venous return)
  - Pericardial Tamponade (rare cause of chest pain, but can cause elevated JVP)
- Normal JVP: Makes right heart failure or significant fluid overload less likely. Does not rule out left ventricular MI, angina, or many other causes of chest pain.
Clinical Reasoning Tip: Elevated JVP in acute chest pain is a concerning sign, prioritize considering PE, RV MI, and tension pneumothorax.

Cardiovascular Examination: Palpate the precordium, assess heart sounds (murmurs, rubs), and check for peripheral oedema

A thorough cardiovascular examination can help to identify or exclude cardiac causes of chest pain.
Relevance:
- New Murmur: Can suggest:
  - Valvular Heart Disease (e.g., aortic stenosis, mitral regurgitation) - may exacerbate angina or be incidental finding.
  - Ventricular Septal Rupture or Mitral Regurgitation post-MI - rare but serious complications of MI, usually with acute severe presentation.
  - Endocarditis (if fever present, less common as primary chest pain cause).
- Pericardial Rub: Highly specific for Pericarditis. May be transient.
- Muffled Heart Sounds: Suggests Pericardial Effusion, potentially progressing to tamponade (rare in acute chest pain context, but consider if acutely unwell).
- Gallop Rhythm (S3 or S4): May suggest heart failure or underlying cardiac dysfunction, but non-specific in acute chest pain.
- Peripheral Oedema: Suggests chronic Heart Failure, less directly relevant to acute chest pain unless decompensated heart failure is presenting. Consider also in pulmonary hypertension secondary to chronic Pulmonary Embolism in subacute presentations.
- Normal Cardiovascular Exam: Common in Angina, Myocardial Infarction, Pulmonary Embolism, Musculoskeletal Chest Pain, GORD, Anxiety. A normal exam *does not rule out serious cardiac conditions*.
Clinical Reasoning Tip: A new murmur or pericardial rub are diagnostically significant. However, a normal cardiovascular exam is frequent and does not exclude critical cardiac diagnoses.

Inspection for Skin Changes: Look for vesicular rash or erythema

Inspection of the skin is important to identify conditions like herpes zoster (shingles).
Relevance:
- Vesicular Rash (Dermatomal Distribution): Strongly suggests Herpes Zoster (Shingles). Consider if chest pain precedes rash onset.
- Erythema, Warmth, Tenderness of Chest Wall: May suggest local infection like Cellulitis or Erysipelas of chest wall (rare cause of primary chest pain, but consider if skin findings prominent).
- Absence of Skin Changes: Helps rule out Herpes Zoster and primary skin infections, but most other chest pain diagnoses will have normal skin exam.
Clinical Reasoning Tip: Vesicular rash in a dermatomal pattern is highly suggestive of Herpes Zoster.

Palpation of the Chest Wall: Palpate the chest wall for tenderness

Palpation of the chest wall is important for identifying musculoskeletal causes of chest pain.
Relevance:
- Localised Chest Wall Tenderness, Reproducible Pain on Palpation: Suggests Musculoskeletal Chest Pain, Costochondritis, or Rib Fracture. Tenderness over costochondral junctions in costochondritis is typical.
- Widespread Tenderness, Non-Specific: May be seen in Fibromyalgia or non-specific chest wall pain, but less specific diagnostically.
- Absence of Chest Wall Tenderness: Reduces likelihood of musculoskeletal chest pain and costochondritis, but does not exclude them entirely (some patients with these conditions have minimal tenderness). More helpful in ruling *in* than ruling *out*.
Clinical Reasoning Tip: Reproducible, localised chest wall tenderness is suggestive of musculoskeletal chest pain or costochondritis. However, absence of tenderness does not exclude these diagnoses.

Respiratory Examination: Assess for chest expansion, breath sounds, percussion notes, and added sounds (crackles, wheeze, pleural rub)

Examination of the respiratory system helps identify or exclude pulmonary causes of chest pain.
Relevance:
- Reduced Chest Expansion (Unilateral): Suggests Pneumothorax (if unilateral reduction), Pneumonia, or pleural effusion.
- Reduced Breath Sounds (Unilateral): Suggests Pneumothorax or pleural effusion. Absent breath sounds are more specific for pneumothorax.
- Hyper-resonant Percussion (Unilateral): Suggests Pneumothorax.
- Dull Percussion: Suggests Pneumonia (consolidation) or pleural effusion.
- Crackles (Crepitations): Suggests Pneumonia or Pulmonary Oedema (if bilateral and cardiac history).
- Wheeze: More suggestive of Asthma or COPD exacerbation (less common as primary cause of *new* acute chest pain, but consider if history of these conditions).
- Pleural Rub: Classic for Pleurisy, also seen in Pulmonary Embolism and Pneumonia (pleuritic involvement).
- Normal Respiratory Examination: Common in Angina, Myocardial Infarction, Pulmonary Embolism (early/small PE), Musculoskeletal Chest Pain, GORD, Anxiety. A normal exam *does not rule out pulmonary embolism or other serious conditions*.
Clinical Reasoning Tip: Unilateral reduced breath sounds and hyper-resonance are key signs for pneumothorax. Crackles suggest pneumonia or pulmonary oedema. Pleural rub raises suspicion for pleurisy or pulmonary embolism. A normal respiratory exam is common and doesn't exclude serious diagnoses.

Abdominal Examination: Palpate the abdomen for tenderness, particularly in the right upper quadrant

Abdominal examination can help identify gastrointestinal causes of chest pain.
Relevance:
- Right Upper Quadrant Tenderness: May suggest Biliary Colic or cholecystitis (consider if pain is colicky or post-prandial).
- Epigastric Tenderness: Suggests GORD, Peptic Ulcer Disease, or Oesophagitis. Less specific, can also be seen in gastritis or pancreatitis.
- Rebound Tenderness, Guarding, or Generalised Abdominal Tenderness: Red flags suggesting peritonitis or acute abdomen, less likely primary cause of *chest* pain unless referred pain pattern very unusual. Consider lower oesophageal rupture (Boerhaave’s - rare, severe).
- Normal Abdominal Examination: Makes biliary colic, peptic ulcer disease, and other primary abdominal causes less likely, but does *not* rule out GORD or Oesophageal Spasm (these often have normal abdominal exams).
Clinical Reasoning Tip: Right upper quadrant tenderness consider biliary causes, epigastric tenderness consider upper GI causes, but abdominal exam is often normal in GORD/oesophageal spasm. Severe abdominal signs are less typical for primary chest pain aetiology.

Examination of the Lower Limbs: Check for signs of deep vein thrombosis (DVT), such as unilateral leg swelling or tenderness

Examining the lower limbs is essential to assess for DVT, which may lead to pulmonary embolism.
Relevance:
- Unilateral Leg Swelling (Calf > Thigh), Calf Tenderness, Palpable Cord: Suggests Deep Vein Thrombosis (DVT), increasing the probability of Pulmonary Embolism. However, DVT can be present *without* obvious leg signs in up to 50% of PE cases.
- Bilateral Leg Swelling: More suggestive of systemic causes like Heart Failure or Chronic Venous Insufficiency, less specific for acute PE risk.
- Absence of Leg Swelling/Tenderness: Reduces suspicion for DVT, but as mentioned, does *not rule out Pulmonary Embolism*. Many PEs originate from pelvic or thigh veins or have already embolized by the time of presentation.
Clinical Reasoning Tip: Unilateral leg swelling/tenderness increases suspicion for DVT and thus PE, but absence of leg signs is common in PE and does not rule it out. Always consider PE in the appropriate clinical context, regardless of leg exam findings.

Working DDx

Common

Must Not Miss

Often Missed

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Common

Must Not Miss

Often Missed

Differential Diagnosis Illness Script

Working DDx Click the checkbox to add the condition to the working DDx list

Common

Must Not Miss

Often Missed

Working DDx Click the checkbox to add the condition to the working DDx list

Common

Must Not Miss

Often Missed

Differential Diagnosis Illness Script

Working DDx

Working DDx