One of the main purposes of early and rapid assessment of a patient with chest pain is to identify life-threatening conditions and, in particular, to “rule-in” or “rule-out” an acute coronary syndrome (ACS). There are various features in the history that are traditionally associated with cardiac ischaemic chest pain and various features that make it less likely.

A thorough description of the pain is the first step in the diagnostic process and will help to make the initial differentiation between cardiac and non-cardiac pain and ischaemic and non-ischaemic pain (See Figure 2 and Table 2). Symptom evaluation will include a description of the character of the pain, the location, severity and radiation of the pain, onset and duration of the pain, relieving and aggravating factors, and associated symptoms. Other important features of the history will include risk factor determination, previous episodes and relevant past medical history.

Table 2: Characteristic description of symptoms associated with major causes of chest pain (3-10)

Condition Description of symptoms
Ischaemic cardiac pain Retrosternal “pressure”, “tightness”, “constricting”
Radiation to shoulders/arms/neck/jaw
Crescendo in nature, related to exertion
Associated with diaphoresis, sweating, nausea, pallor
Pericarditis Atypical, retrosternal, sometimes pleuritic
Positional relieved on sitting forward
Gastro-oesophageal Retrosternal, “burning”
Associated with ingestion
Aortic dissection “Tearing” pain, sudden in onset, severe or worst ever pain, radiation to back
Pulmonary embolism Atypical, may be pleuritic
Associated with breathlessness; occasional haemoptysis
Pneumothorax Pleuritic, sharp, positional; sudden in onset
Associated with breathlessness
Pneumonia Atypical, may be pleuritic
Associated with cough, sputum, fever
Musculoskeletal Sharp, positional, pleuritic
Aggravated by movement, deep inspiration and coughing

Figure 2: Cardiac and non-cardiac causes of chest pain