Evaluation of chest pain

Overview 
Theory 
Emergencies 
Diagnosis 
Resources 

Last reviewed: 21 Aug 2025

Last updated: 25 Oct 2024

Chest pain is a common chief complaint, accounting for approximately 5.6% of all emergency department visits in the US per year.[1] It is the presenting complaint in approximately 0.5% of office-based visits.[2]

Chest pain may be caused by either benign or life-threatening etiologies, and is usually divided into cardiac and noncardiac causes.

Acute coronary syndrome (ACS; encompassing unstable angina, ST-elevation myocardial infarction, and non-ST-elevation myocardial infarction) may not be the most common etiology in patients presenting with chest pain. Excluding ACS is, however, vital because of the mortality associated with untreated myocardial infarction.

This topic concentrates on the evaluation of acute chest pain in the emergency setting.

Differentials

Common

Acute coronary syndrome
Stable angina
Pneumonia
Viral pleuritis
GERD
Costochondritis
Anxiety or panic disorder

Full details

Uncommon

Pulmonary embolism
Pericarditis
Cardiac tamponade
Aortic dissection
Aortic stenosis
Mitral valve prolapse
Pneumothorax
Pulmonary hypertension
Peptic ulcer disease
Esophageal spasm
Acute cholecystitis
Acute pancreatitis
Herpes zoster
Gastritis
E-cigarette or Vaping product use Associated Lung injury (EVALI)
Vasospastic angina

Full details

Contributors

Authors

James E. Brown, MD, MMM

Professor and Chair

Emergency Medicine

Wright State University Boonshoft School of Medicine

Fairborn

Disclosures

JEB declares that he has given expert testimony in matters related to this topic.

Acknowledgements

Dr James E. Brown would like to gratefully acknowledge Dr Marvin H. Eng and Dr Mori J. Krantz, previous contributors to this topic.

Disclosures

MHE declares that he has no competing interests. MJK is a consultant for GlaxoSmithKline.

Peer reviewers

Michael Jelinek, MD, FRACP, FACC

Cardiologist

St Vincent’s Hospital Melbourne

Associate Professor

Department of Medicine

University of Melbourne

Melbourne

Australia

Disclosures

MJ declares that he has no competing interests.

Debabrata Mukherjee, MD

Gill Foundation Professor of Interventional Cardiology

Director of Cardiac Catheterization Laboratories

Gill Heart Institute

Division of Cardiovascular Medicine

University of Kentucky

Lexington

Disclosures

DM declares that he has no competing interests.

Martin Bocks, MD

Clinical Lecturer

University of Michigan Congenital Heart Center

Ann Arbor

Disclosures

MB declares that he has no competing interests.

Ethan Cumbler, MD

Assistant Professor

Department of Internal Medicine

University of Colorado Health Sciences Center

Denver

Disclosures

EC declares that he has no competing interests.

Davendra P.S. Sohal, MBBS, MPH

Research Fellow

Internal Medicine

Albert Einstein College of Medicine/Jacobi Medical Center

Bronx

Disclosures

DS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2021 Nov 30;144(22):e368-454.Full text Abstract

Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. circulation. 2014 Dec 23;130(25):e344-426.Full text Abstract

National Institute for Health and Care Excellence. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Nov 2016 [internet publication].Full text

O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425.Full text Abstract

Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Evaluation of chest pain

Summary

Differentials

Common

Uncommon

Contributors

Authors

James E. Brown, MD, MMM

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Michael Jelinek, MD, FRACP, FACC

Disclosures

Debabrata Mukherjee, MD

Disclosures

Martin Bocks, MD

Disclosures

Ethan Cumbler, MD

Disclosures

Davendra P.S. Sohal, MBBS, MPH

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice