Initial Triage and History-Taking
The chest pain workup begins before any test is ordered. Emergency clinicians and primary care providers first assess hemodynamic stability, airway, breathing, and circulation. They identify red flags such as hypotension, diaphoresis, dyspnea, syncope, or signs of shock, which demand immediate intervention. Equally important is a focused history that characterizes the pain by onset, duration, quality, radiation, and aggravating or relieving factors. Pain described as pressure, squeezing, or heaviness radiating to the jaw or left arm raises suspicion for cardiac ischemia, while pleuritic chest pain that worsens with inspiration or coughing points toward pulmonary or pericardial causes. A thorough review of risk factors — age, smoking, diabetes, hypertension, dyslipidemia, family history of premature coronary disease, and use of oral contraceptives or stimulants — shapes the pretest probability of coronary artery disease.
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During the physical exam, providers look for asymmetry of pulses, blood pressure differentials suggestive of aortic dissection, signs of heart failure such as elevated jugular venous pressure or pulmonary crackles, and murmurs of valvular disease. Abdominal tenderness, rash, or chest wall tenderness can redirect suspicion away from the heart. This initial synthesis of history and exam determines which diagnostic tests are ordered next.
Electrocardiogram and Cardiac Biomarkers
The 12-lead ECG is the cornerstone of the early chest pain workup. It should be obtained and interpreted within 10 minutes of arrival in any setting where acute coronary syndrome is suspected. ST-segment elevation or depression, new bundle branch blocks, T-wave inversions, and pathological Q waves each carry specific implications. A normal ECG does not rule out ischemia, particularly in early presentation or in women and diabetic patients who may have atypical patterns.
Serial high-sensitivity cardiac troponin measurements are the standard for detecting myocardial injury. Protocols such as the 0-hour/1-hour or 0-hour/2-hour high-sensitivity troponin algorithms allow clinicians to rule out acute myocardial infarction rapidly when values remain below the limit of detection and show no significant rise or fall. These algorithms reduce chest pain unit length of stay, but they depend on assay-specific cutoffs and validated institutional pathways. Clinicians also consider other biomarkers when the diagnosis remains unclear, such as D-dimer in the setting of suspected pulmonary embolism or inflammatory markers in possible myocarditis or pericarditis.
Risk Stratification Scores
For patients with stable chest pain and a non-diagnostic ECG, structured risk scores help decide between early discharge, further observation, or referral for invasive angiography. The HEART score assigns points based on History, ECG findings, Age, Risk factors, and Troponin levels, stratifying patients into low, intermediate, and high-risk groups. The TIMI risk score for unstable angina and non-ST-segment elevation myocardial infarction similarly estimates 14-day adverse event risk using seven variables. In the emergency department, the TIMI and GRACE scores inform decisions about discharge versus admission and the urgency of cardiology consultation. These scores are adjuncts, not replacements for clinical judgment, and they perform best when applied to populations similar to those in the derivation studies.
Imaging and Advanced Testing
When the initial workup leaves the diagnosis uncertain, imaging plays a central role. Computed tomography pulmonary angiography is the reference standard for ruling out pulmonary embolism in patients with a Wells score that places PE in a moderate or high probability range. Chest radiography helps identify pneumothorax, pneumonia, pleural effusion, or widened mediastinum that could suggest aortic dissection. Transthoracic echocardiography evaluates wall motion abnormalities, pericardial effusion, valvular function, and right ventricular strain patterns. For patients with stable chest pain and intermediate pretest probability of coronary disease, stress testing — whether exercise electrocardiography, stress echocardiography, or myocardial perfusion imaging — can assess for inducible ischemia. Coronary CT angiography provides a non-invasive anatomical assessment of coronary stenosis and is increasingly used in chest pain units to fast-track low-to-intermediate risk patients. Invasive coronary angiography remains the definitive test when high-risk features, ongoing symptoms, or positive stress results warrant direct visualization and potential revascularization.
Differential Diagnosis and Non-Cardiac Causes
A complete chest pain workup keeps a broad differential in mind. Gastroesophageal reflux disease and esophageal spasm can mimic cardiac pain and are often evaluated with a trial of proton pump inhibitors or esophageal manometry when symptoms are refractory. Musculoskeletal chest wall pain is suggested by reproducible tenderness and is a diagnosis of exclusion. Panic attacks and anxiety can produce chest discomfort accompanied by hyperventilation, palpitations, and paresthesias, but this diagnosis requires ruling out organic causes first. Pulmonary causes such as pleuritis, pneumonia, or pneumothorax are confirmed by imaging and auscultation. Aortic dissection, though uncommon, should be considered in patients with tearing pain radiating to the back and blood pressure asymmetry between arms.
Disposition and Follow-Up Planning
The endpoint of the chest pain workup is a disposition decision: discharge home with outpatient follow-up, observation in a chest pain unit, admission to a telemetry ward, or transfer to a higher level of care. Low-risk patients with normal ECGs, undetectable or stable troponin, negative stress testing, and low-risk scores can often be safely discharged with clear return precautions and expedited outpatient cardiology or primary care follow-up. Intermediate-risk patients may benefit from a period of observation, repeat biomarker testing, or non-invasive imaging before a final determination. High-risk patients require immediate cardiology involvement, consideration of invasive angiography, and admission to a monitored setting. Discharge instructions should include explicit guidance on symptoms that warrant return to the emergency department, medication adherence, and follow-up appointments within a defined timeframe.