Approach to acute chest pain

The order of the asking

The approach to chest pain runs in a fixed order, and the first item settles how fast the rest must move:

• Etiology, maybe benign or life threatening?
• Risk factor for IHD?
• History of chest pain: pleuritic, tender, positional?
• Duration? Location? Radiation? Precipitating factors?
• Alleviating factors: rest, nitroglycerin?

Everything after the first line is history taken with that split in mind. The material puts the risk factor item as a question and does not itself list the risk factors for IHD.

The causes, sorted by where they sit

Chest pain is set out by the organ it comes from:

• Heart: MI, aortic dissection, cardiac tamponade, pericarditis, myocarditis, endocarditis
• Pulmonary: PE, pneumonia, asthma and COPD, acute chest syndrome
• Pleura: pleuritis, pneumothorax including tension pneumothorax
• Esophagus: esophageal spasm, eosinophilic esophagitis, esophageal rupture or perforation, GERD
• Chest wall: costochondritis and other musculoskeletal pain
• RUQ pathology
• Panic attack

Laid over that list is a second one, the life threatening causes, held on the mnemonic PET MAP:

• Pulmonary embolism
• Esophageal rupture
• Tamponade
• MI and angina
• Aortic dissection
• Pneumothorax

Those six are what the first question of the approach is asking about. The list by organ tells you where to look; PET MAP tells you what cannot wait.