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Chest Pain Triage & Evaluation

Chest pain is a symptom that must always be assumed cardiac until proven otherwise. While the majority of chest pain presentations in primary care are non-cardiac, the potential severity of acute coronary syndrome (heart attack) dictates strict triage protocols.

CALL 911 / Go to the Emergency Room IF:

Do not drive yourself. Call emergency services if you experience chest pain accompanied by:

  • Pain radiating down the left arm, into the jaw, or into the back
  • Sensation of crushing pressure, squeezing, or "an elephant on your chest"
  • Shortness of breath, sweating (diaphoresis), or extreme nausea
  • Dizziness, lightheadedness, or feeling like you might pass out
  • Pain that worsens with physical exertion and improves with rest

Base Rates in Primary Care

In outpatient primary care settings (excluding the Emergency Department), the causes of chest pain breakdown approximately as follows:

  • Musculoskeletal (Chest wall pain): 36-49%
  • Cardiovascular (Ischemic): 15-16%
  • Gastrointestinal (GERD, Esophageal): 8-19%
  • Psychiatric (Panic attacks, anxiety): 8-11%
  • Pulmonary (Asthma, PE, Pneumonia): 5-10%

Differentiating Non-Cardiac Causes

If emergency cardiac causes have been ruled out by a physician (via EKG and Troponin blood tests), the next step is identifying the exact non-cardiac origin.

1. Musculoskeletal Pain (Costochondritis)

  • Key Feature: The pain is reproducible. If you press firmly on the cartilage connecting the ribs to the breastbone and it hurts, it is highly likely musculoskeletal.
  • Aggravation: Worsens with specific twisting motions, coughing, or deep inspiration.

2. Gastroesophageal Reflux Disease (GERD)

  • Key Feature: Burning sensation (heartburn) located behind the sternum.
  • Aggravation: Worsens when lying down flat, eating large/spicy meals, or drinking alcohol.
  • Relief: Often temporarily relieved by antacids.

3. Panic / Anxiety Attacks

  • Key Feature: Sudden onset of intense fear accompanied by rapid heart rate, hyperventilation, and chest tightness.
  • Context: A diagnosis of exclusion. Cardiac causes must be ruled out first.