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


Iatrogenic related to cardiac catheterisation

Coarctation of the aorta


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%) .. ..