Acute chest pain is a common presenting complaint: it accounts for approximately 700,000 presentations to the emergency department (ED) per year in England and Wales and for up to 25% of emergency medical admissions(1).

Chest pain is caused by a spectrum of pathology ranging from the innocent to the extremely serious (see Table 1); amongst the latter are a number of conditions which are potentially catastrophic and can cause death within minutes or hours. There are, however, treatments available to improve symptoms and prolong a life, hence why it is a crucial role of the emergency physician to robustly identify the significant minority of patients with serious pathologies.

The large volume of patients presenting with a potentially serious condition places chest pain at the very core of emergency medicine work. Clinicians need to be skilled at focused history taking and avoid unnecessary investigations and admission for the majority of patients who can be safely discharged. This is a difficult challenge: it has been reported that 6% of patients discharged from a UK emergency department have subsequently been proven to have prognostically significant myocardial damage (2).

Table 1 The spectrum of pathology presenting with chest pain
System Life-threatening Urgent Non-urgent
  • Acute myocardial infarction
  • Aortic dissection
  • Pulmonary embolism
  • Unstable angina
  • Coronary vasospasm
  • Pericarditis
  • Myocarditis
  • Stable angina
  • Valvular heart disease
  • Hypertrophic cardiomyopathy
  • Tension pneumothorax
  • Simple pneumothorax
  • Viral pleurisy
  • Pneumonia
  • Costochondritis
  • Chest wall injury
  • Oesophageal rupture
  • Pancreatitis
  • Cholecystitis
  • Oesophageal reflux
  • Biliary colic
  • Peptic ulcer
  • Mediastinitis
  • Postherpetic neuralgia
  • Herpes zoster
  • Malignancy
  • Psychological/anxiety


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