Chest wall / musculoskeletal: Localized tenderness or movement-related pain; reproducibility alone does not exclude ACS
Pulmonary / infectious: Pneumonia or another pulmonary process
Anxiety-related symptoms: Assess in context—not simply because the initial tests are negative
Before discharge: Reassess symptoms, vital signs, and examination. Persistent concerning findings require further evaluation; a low-risk ACS assessment does not exclude another dangerous diagnosis
Follow-up / return precautions: Address recurrent or worsening symptoms and unresolved diagnostic concerns.
01Resuscitation / Initial Evaluation
Resuscitation and evaluation proceed together. Obtain the ECG and focused bedside assessment during resuscitation—not afterward.
Early ECG applies to stable and unstable patients.
TEE → useful when unstable / unsafe to leave bedside or CT unavailable
MRI → accurate alternative when clinically practical ACC/AHA 2022
Chest X-Ray
May show mediastinal widening or abnormal aortic contour
May identify another cause of pain
Normal CXR does not exclude dissectionACC/AHA 2022
POCUS
POCUS may rapidly identify:
Pericardial effusion / tamponade
Dilated aortic root
Visible dissection flap
Acute AR / LV dysfunction
Negative POCUS does not exclude dissection.
A prospective pilot study found ED POCUS sensitivity 86.4% and specificity 100% compared with CTA; useful as an adjunct, not a rule-out test. Wang et al.
D-Dimer / ADD-RS
ADD-RS: One point for each positive domain—predisposition, pain, examination; total 0–3. The score alone does not exclude acute aortic syndrome
Do not use D-dimer alone to rule out dissection
High clinical suspicion → CTA
Selected low-pretest-probability patients:
ADD-RS + D-dimer may help avoid unnecessary CTA
D-dimer <500 ng/mL with a low ADD-RS makes AAS unlikely ACC/AHA 2022
A 2024 meta-analysis found ADD-RS + D-dimer strategies highly sensitive, with the expected trade-off between sensitivity and the number of patients sent for imaging. Meta-analysis 2024
Position: Worse supine → improves sitting up / leaning forward
Pericardial friction rub: Supports diagnosis; absence does not exclude
Inflammatory context: Recent respiratory illness / systemic inflammatory disease may support the diagnosis but does not establish etiology Imaging Statement 2024
Diagnostic Criteria
ACC 2025 proposed diagnostic criteria:
Pleuritic chest pain or equivalent with a suggestive clinical presentation must be present
Large effusion alone: Does not equal tamponade; management depends on physiology and cause
Uncomplicated inflammatory effusion without tamponade: Treat the inflammation; routine drainage is unnecessary. Specialist-directed drainage may be indicated for suspected bacterial / TB / malignant disease or symptomatic / refractory effusion Imaging Statement 2024ACC 2025
Myocarditis
Suspected myocardial involvement: ↑Troponin / new ventricular dysfunction
Myocarditis not established by troponin alone: Exclude competing causes, especially ACS
High risk: HF / shock / ventricular arrhythmia / advanced AV block
ICAP trial: 240 patients; colchicine added to aspirin / ibuprofen reduced incessant or recurrent pericarditis from 37.5% → 16.7%. ICAP
Discharge
Stability: Hemodynamically stable
Risk: No high-risk features
Symptoms: Controlled
Treatment: Tolerating oral therapy
Complications: No tamponade / significant myocardial involvement
Follow-up: Reliable early reassessment
Complete pain resolution not required before discharge.
Structured outpatient care succeeded in 87% of selected low-risk patients in the original cohort; treatment failure prompted hospitalization. Outpatient Study
Activity: Avoid strenuous exercise during active disease; return guided by clinical remission / follow-up ACC 2025
Boerhaave: Forceful vomiting / retching followed by sudden severe retrosternal / lower chest / upper abdominal pain
Odynophagia / dysphagia / dyspnea
Subcutaneous emphysema supports the diagnosis but is not required
Iatrogenic perforation: New chest / neck / abdominal pain after endoscopy or instrumentation
Delayed presentation: Fever / sepsis / shock
Boerhaave syndrome: Spontaneous full-thickness esophageal perforation; instrumentation, trauma, and caustic injury cause esophageal perforation but are not Boerhaave syndrome
Diagnosis
Chest X-Ray
Pneumomediastinum
Pleural effusion
Pneumothorax
Subcutaneous emphysema
Limitation: Normal CXR does not exclude esophageal perforation
CT Esophagram
Preferred initial diagnostic study
Identifies the perforation and extent of mediastinal / pleural contamination
Helps distinguish contained vs free leak
Helps guide definitive management
STS 2026: Favors CT esophagram over fluoroscopic esophagram for initial diagnosis
Additional Testing
Contrast esophagram: Selected cases when CT remains equivocal or the leak needs further definition
Endoscopy: Selected diagnostic cases or when incorporated into treatment STS 2026
Initial Treatment
NPO
IV fluids / resuscitation as needed
Broad-spectrum IV antibiotics
Early thoracic surgery / esophageal-team consultation
Contamination: Drain significant pleural / mediastinal collections when needed
Treatment goals: Infection control + closure of perforation + control of mediastinal / pleural contamination
Mackler triad: Vomiting + chest pain + subcutaneous emphysema; absence does not exclude
Diagnosis: CT esophagram
Treatment: Same perforation principles—stability, containment, contamination, and sepsis determine management
Evidence: Primary surgical repair remains the most common definitive treatment; endoscopic therapy is an increasingly used option in selected patients Meta-analysis 2026
Pneumothorax
Consider pneumothorax: Sudden pleuritic chest pain / dyspnea, asymmetric breath sounds, or a relevant traumatic / pulmonary history
Suspected tension pneumothorax + instability: Immediate decompression; do not wait for imaging. See Trauma - Blunt Chest for the decompression pathway
Stable spontaneous pneumothorax: Confirm the diagnosis and assess symptoms, physiology, and underlying lung disease; detailed management belongs in the dedicated pathway ERS/EACTS/ESTS 2024
See Pneumothorax / Dyspnea Algorithm — Coming soon
ECG within 10 minutes, with initial hs-cTn obtained promptly
Compare previous tracings when available
Persistent / recurrent symptoms or deterioration → repeat ECG
Evaluate ACS and other dangerous causes together; do not postpone the ECG while completing the rest of the chest-pain differential
Figure 1 — Pathway Summary: Kontos et al., ACC 2022, original Figure 1. Source
Figure note (*): Unchanged or minimally changing serial hs-cTn with reassuring context: normal coronary angiography within 2 years or stress testing within 1 year; symptoms inconsistent with ACS; chronic elevations matching prior values; or modified HEART ≤3 / EDACS <16
STEMI / Acute Coronary Occlusion Pattern
STEMI / acute coronary occlusion pattern → separate reperfusion pathway
Figure 2 — High-STEACS Early Rule-Out CDP: ACC 2022, original Figure 4. This is a specific pathway; use locally validated assays and thresholds. Source
Figure note (*): Trials accepted onset ≥2 hours before presentation; ACC recommends ≥3 hours between symptom onset and the first sample for immediate rule-out
Figure note (†): Arrange outpatient follow-up and selective testing; see source Sections 5.6 and 5.8
Figure note (‡): Additional evaluation may include observation / admission and anatomical or functional testing. Classify injury and treat acute MI appropriately; stable chronic injury may permit outpatient care. See Sections 5.6–5.8. The figure uses the 2022 MI terminology; the updated classification is described below
Selected Single-Draw Rule-Out
Nonischemic ECG + reassuring clinical assessment
Symptoms began ≥3 hours before the sample
hs-cTn below the institution’s validated very-low rule-out threshold
Not simply “one normal troponin”
Early / uncertain symptom onset or concerning findings require further assessment
Discharge with follow-up when no other admission indication exists
No routine urgent stress test / coronary CTA / inpatient cardiac testing
HEART / EDACS: Not automatically required after a validated hs-cTn rule-out; use when incorporated into the institutional pathway or residual concern remains
Persistent concern for acute ischemia or another dangerous diagnosis requires further evaluation
Modified HEART (HEAR; ACC 2022): History, ECG, age, and risk factors; 0–8 points. This version excludes troponin and must be paired with the appropriate troponin pathway
EDACS: Use the score within a validated clinical decision pathway; a score <16 alone is insufficient for discharge
Not ruled out; not clearly assigned to the abnormal / high-risk group
Repeat hs-cTn at 3–6 hours
Reassess symptoms / ECG; compare prior troponin values and review known CAD / previous cardiac testing
HEART / EDACS: May help refine disposition
Further testing: Selective coronary CTA / stress testing based on the remaining concern, known CAD, and prior results
Disposition: Selected patients may leave after reassuring reassessment with rapid follow-up; others need further observation or admission
Intermediate risk ≠ unstable angina: The evaluation is still incomplete
Acute injury: Troponin rise / fall with at least one value above the sex-specific 99th percentile, without sufficient evidence of infarction
Chronic injury suspected: Persistently elevated hs-cTn without a significant acute change; review prior values, clinical stability, and the underlying cause before confirming
Identify the cause rather than labeling every elevation NSTEMI
Convincing acute ischemia without acute myocardial injury → unstable angina
Troponin elevation without acute MI → acute / chronic myocardial injury
No ACS established → evaluate other causes / determine disposition
Negative troponins alone → neither an unstable-angina diagnosis nor automatic discharge
04Other Causes Of Chest Pain
Emergent causes addressed / ACS risk assessed → evaluate other cardiac and noncardiac causes. A low-risk ACS assessment does not exclude another dangerous diagnosis.
Stable Angina
Consider: A reproducible exertional pattern without a new or worsening acute pattern
Acute change matters: New rest pain, increasing frequency / severity, or a concerning ECG / troponin pattern returns the patient to ACS evaluation
Disposition: Arrange appropriate follow-up and selective further evaluation based on known CAD, symptoms, and prior testing AHA/ACC 2021
Differential
GI / esophageal: GERD, esophagitis / esophageal spasm, gastritis / PUD, biliary disease, pancreatitis → see Abdominal Pain — Upper.
Chest wall / musculoskeletal: Costochondritis, muscle strain, rib injury. Reproducible tenderness supports a chest-wall source but does not independently exclude ACS.
Anxiety / panic / hyperventilation: Assess in context—not simply because initial testing is negative.
Before Discharge
Reassess symptoms, vital signs, and examination. Persistent concerning findings → further evaluation; otherwise provide symptom-directed care, follow-up, and return precautions.
