Cardiology

Approach to chest pain

Written 30 September 2026.

Why this matters

Chest pain is common. A few causes kill quickly, and they do not all look like a heart attack.

Rapid clinical summary

First decide whether the patient is unstable.
Then look for the causes you cannot send home: coronary occlusion, pulmonary embolism, dissection, pneumothorax, and esophageal rupture.
A normal oxygen saturation does not exclude ischemia.

Mechanism

Pain fibers from the heart, aorta, pleura, and esophagus share pathways. The history is about character, timing, and associated collapse or breathlessness — not about how worried the person looks.

Recognition

If you cannot say why this pain is safe, it is not safe yet.

Typical

Pressure with exertion
Pleuritic pain with breathlessness
Tearing pain to the back
Pain after vomiting

Red flags

Ongoing pain
Shock
Sudden breathlessness
A new neurological deficit with the pain
Unequal pulses

Differential

Condition	Clue	Trap
Acute coronary syndrome	Pressure, sweat, exertion	Waiting for a troponin before the ECG
Pulmonary embolism	Sudden dyspnea, pleuritic pain, a risk	Calling every clear chest an infection
Aortic dissection	Tearing pain, pulse deficit, neurological change	Treating it as infarction and giving the wrong drug pathway
Pneumothorax	Sudden pleuritic pain, reduced breath sounds	A chest X-ray that was never done
Esophageal rupture	Pain after vomiting, subcutaneous air	Labeling it reflux because it followed a meal

Investigations

ECG immediately when ischemia is possible.
The next test follows the leading dangerous diagnosis. It is not the same test for every chest pain.

Management

Immediate: Support airway, breathing, and circulation if any of those are failing. Get the ECG if the story could be cardiac.
Definitive: The definitive step is the one that matches the diagnosis: reperfusion for occlusion, a surgical pathway for dissection or rupture, drainage for a tension pneumothorax. This page does not state drug doses.
Monitoring: Repeat the assessment if pain, blood pressure, or conscious level changes. One set of normal observations does not retire the diagnosis.

Common pitfalls

Using oxygen saturation as a test for ischemia.
Discharging ongoing pain.
Forcing every chest pain down a single ACS pathway.

Exam reasoning

Exams often ask for the next step, not the full differential. Stability and the one finding that does not fit are the discriminator.

Practice this topic

Opens original Mahazanaka questions in this subject. If this subject is thin on that track, the session uses what exists.

Visual summary

Chest pain: what you cannot miss

Five dangerous causes before a benign label.

Recognize, reason, prioritize, act safely

Recognize. Pain plus a time course and one associated feature.
Reason. Which structure could kill in the next hour?
Prioritize. Unstable features before a complete list of benign causes.
Act safely. The test or treatment that addresses that structure. Not a routine clinic.

Knowledge check

A patient has ongoing chest pressure and a normal oxygen saturation. Is it reasonable to send them home without an ECG?
Tearing pain to the back and a pulse deficit. Why is an automatic ‘heart attack drug pathway’ the wrong reflex?

No citation is attached to this chapter. Nothing here is personal medical advice.