Chest Pain Score
Various studies have used a “chest pain score” (based upon ascribing positive or negative points to typical or atypical aspects of chest pain location, character, radiation, onset, and associated symptoms(17)) and then combined this with historical risk factors to generate positive predictive values for ruling in or ruling out an acute coronary syndrome(18,19). However, this approach has not led to sufficiently robust positive likelihood ratios to definitively rule in ACS (i.e. commit to specific therapies) or rule out ACS (i.e. allow safe discharge).
Other life-threatening conditions present with chest pain other than ACS. The above discussion of likelihood applies specifically to AMI. The clinician will have to consider the presenting features in the history that are typical of other conditions (e.g. a “tearing” feeling and radiation to the back in aortic dissection (see Table 5), or haemoptysis and shortness of breath in pulmonary embolism) alongside risk factors specific to these conditions (see Table 4) in order to narrow the differential diagnosis and guide subsequent investigation and management.
Table 4: Risk factors associated with major life-threatening causes of chest pain
| Condition | Risk Factors |
| Acute coronary syndromes | Previous known coronary artery disease (previous myocardial infarction, angioplasty, etc)
Positive family history Advanced age, male gender Diabetes, hypertension, hypercholesterolaemia Active smoker, obesity, sedentary lifestyle Aspirin usage |
| Aortic dissection(6,7) | Chronic hypertension
Inherited connective tissue disorder e.g. Marfans Syndrome, Ehlers-Danlos Syndrome Bicuspid aortic valve Atheroscleroisis Iatrogenic related to cardiac catheterisation Coarctation of the aorta Pregnancy Cocaine use Inflammatory aortic disease e.g. Giant Cell Arteritis |
| Pulmonary embolism(8,9) | Previous history of venous thromboembolic disease
Pregnancy particularly 6 weeks post partum Positive family history of venous thromboembolic disease (two or more family members) Recent prolonged immobilisation (> 3 days) Major surgery within previous 12 weeks Fracture of lower limb within previous 12 weeks Active cancer (within previous 6 months, recent treatment, palliation) Lower extremity paralysis |
Table 5: Presenting features of aortic dissection as per the international Registry of Acute Aortic Dissection(5)
| Symptom | Type A (n=617) | Type B (n=384) | Overall (n=1001 except * n=381) |
| Chest or Back Pain | 507 (85%) | 328 (86%) | 835 (85%) |
| Severe or worst-ever pain | 211 (90%)* | 135 (90%)* | 346 (90%)* |
| Abrupt onset of pain | 453 (91%) | 332 (89%) | 785 (90%) |
| Migrating pain | 85 (15%) | 80 (25%) | 175 (19%) |
| Pain presenting within 6hrs of symptoms | 334 (79%) | .. | .. |