Chest pain on the ward
The staff nurse calls about chest pain. Ask for an ECG now, go and see the patient, and think ACS, PE, dissection and pneumothorax.
"Bed 6 has chest pain." He is 64, diabetic, a smoker, day 2 after a knee replacement. Central chest tightness for 20 minutes spreading to the left arm, sweaty and nauseated. BP 148/90, pulse 96, SpO₂ 96% on air. He is on enoxaparin 40 mg daily.
What do you do in the first 10 minutes, and what do you need to discuss with the surgeons?
- ECG within 10 minutesCompare with any previous ECG. Repeat if pain continues or changes.
- Observations and A–EPain score, BP in both arms if pain is tearing or goes to the back.
- Think of the big fiveACS, PE, aortic dissection, pneumothorax, oesophageal rupture.
- TroponinAt baseline and repeat per local pathway.
- Treat as you goOxygen only if below target. GTN if BP allows. Aspirin if ACS likely and no contraindication.
- After surgeryBleeding risk changes the antithrombotic plan: speak to the surgeon and your senior.
- Don't call it musculoskeletalUntil the ECG and troponins say so.
- ST elevation or new LBBB
- Low BP, new arrhythmia, breathlessness, pulmonary oedema
- Tearing pain or BP difference between arms
- Hypoxia with a clear chest (PE)
- Post-operative patient with suspected ACS and bleeding risk
- Pain after vomiting with surgical emphysema
- STEMI
- Pulmonary embolism
- Aortic dissection
- Tension pneumothorax (after a central line)
- Oesophageal rupture (after vomiting or endoscopy)
- Pericarditis and tamponade
- Perforated ulcer or pancreatitis presenting as chest pain
| ECG | Within 10 minutes of chest pain, repeat with ongoing pain |
| Aspirin | 300 mg chewed if ACS suspected and no contraindication (check with the surgeon after surgery) |
| GTN | 400 micrograms sublingual if systolic above 90 and no PDE5 inhibitor |
| Morphine | 2.5–5 mg IV titrated, with an antiemetic |
| Oxygen | Only if SpO₂ below 94% |
| STEMI | New ST elevation in 2 contiguous leads or new LBBB with symptoms: STEMI pathway |
Check every dose against a current drug reference and your hospital protocol.
On this page
On the phone
- Where is the pain, what is it like, how long, does it go anywhere?
- Observations? Breathless? Sweaty?
- Why was the patient admitted? Recent surgery, procedure, central line, endoscopy?
- Ask the nurse to do a 12-lead ECG now and send it to you or keep it for when you arrive.
When you arrive
- ECGLook for ST elevation, new LBBB, ST depression, T inversion, arrhythmia, right heart strain.
- A–ESpO₂, RR, chest (pneumothorax, crackles), pulse, BP both arms, JVP, heart sounds (pericardial rub, new murmur).
- HistoryCharacter, radiation, onset, pleuritic or not, risk factors, recent procedures.
- BloodsTroponin, CBC, electrolytes, creatinine, clotting, glucose.
- Chest X-rayPneumothorax, widened mediastinum, pneumonia, free air.
- Treat and callPer likely cause.
Which chest pain?
- STEMI pathway now
- see the ACS guide
- Possible NSTEMI
- serial troponin, senior
- Think PE
- Wells, CTPA
- Think dissection
- no antithrombotics
- CT aortogram
- Pericarditis
- NSAID, colchicine, echo
- Oesophageal rupture
- CT, surgeons
Differential diagnosis
| Cause | Clues | Test |
|---|---|---|
| ACS | Central pressure, radiation to arm or jaw, sweating, risk factors | ECG, troponin |
| PE | Pleuritic, breathless, fast pulse, hypoxia, post-op or immobile | Wells, CTPA |
| Aortic dissection | Sudden tearing pain to the back, unequal arm BP, new aortic regurgitation | CT aortogram |
| Pneumothorax | Sudden pleuritic pain, reduced breath sounds, after a central line | Chest X-ray |
| Pericarditis | Sharp, better sitting forward, rub, saddle ST elevation | ECG, echo |
| Oesophageal rupture | After vomiting or endoscopy, surgical emphysema | CT with contrast |
| Pneumonia | Fever, cough, crackles | Chest X-ray |
| Musculoskeletal | Reproducible tenderness, normal ECG and troponin | Diagnosis of exclusion |
| GI (reflux, ulcer, pancreatitis, gallbladder) | Epigastric, related to food | Amylase, LFTs |
Post-operative chest pain
- MI after surgery is common and often silent or atypical (breathlessness, low BP, arrhythmia). Troponin rise with ECG changes matters.
- PE is common after joint replacement, pelvic and abdominal surgery, even on prophylaxis.
- Before aspirin, heparin or thrombolysis, speak to the surgeon about bleeding risk. Thrombolysis is usually contraindicated soon after surgery; primary PCI may still be possible.
- Central line in the last hours? Think pneumothorax.
Treatment
See acute coronary syndrome, pulmonary embolism and chest pain in the emergency.
Common mistakes
- Waiting for the troponin before doing an ECG.
- Calling chest pain "musculoskeletal" or "gastritis" without an ECG.
- Giving aspirin or heparin to a possible dissection.
- Forgetting PE in a post-operative patient with a clear chest.
- Missing a pneumothorax after a central line.
- Not involving the surgeon before antithrombotics after an operation.
Document
Time of pain, ECG findings and time, troponin times, treatment given, who you discussed with and the plan.
Frequently asked questions
What should I do first for chest pain on the ward?
Get a 12-lead ECG within 10 minutes, check observations and assess for ACS, PE, dissection, pneumothorax and oesophageal rupture.
Can I give aspirin for chest pain after surgery?
If ACS is likely, aspirin is usually given, but discuss the bleeding risk with the surgical team and your senior first.
What are the signs of pericarditis on ECG?
Widespread saddle-shaped ST elevation and PR depression, without the reciprocal changes of a STEMI.
Which chest pains must not be missed?
ACS, pulmonary embolism, aortic dissection, tension pneumothorax and oesophageal rupture.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A diabetic patient on day 2 after knee replacement has central chest tightness. What is the first investigation?
Answer: 12-lead ECG. An ECG within 10 minutes identifies STEMI and other urgent patterns.
- D-dimer: Not first.
- Exercise test: Contraindicated.
- Chest X-ray: Not first.
- Echocardiogram: Not first.
2. A patient has sharp chest pain worse lying flat and better sitting forward, with widespread saddle-shaped ST elevation and PR depression. What is the diagnosis?
Answer: Acute pericarditis. Pericarditis: NSAID (or aspirin) and colchicine if no contraindication.
- Anterior STEMI: ST elevation is regional with reciprocal change.
- Pulmonary embolism: Different ECG.
- Oesophageal spasm: No ECG changes.
- Aortic dissection: Different pain.
3. Before giving aspirin to a post-operative patient with suspected ACS, what should you do?
Answer: Discuss bleeding risk with the surgical team. Post-operative bleeding risk changes antithrombotic decisions; involve seniors and surgeons.
- Thrombolyse: Contraindicated soon after surgery.
- Wait 48 hours: Too long if ACS.
- Give heparin instead: Bleeding risk too.
- Nothing, give it immediately in all: Bleeding risk matters after surgery.
4. Which ECG pattern favours acute pericarditis over STEMI?
Answer: Widespread saddle ST elevation + PR depression. Pericarditis ECG: diffuse concave (saddle-shaped) ST elevation across multiple territories, PR depression (PR elevation in aVR), no reciprocal ST depression (except aVR, V1), no Q waves; evolves through stages over days. STEMI: convex ST elevation in a coronary territory with reciprocal depression, Q waves later. Echo looks for effusion; troponin may rise in myopericarditis.
- Regional ST elevation with reciprocal depression: Regional ST elevation with reciprocal depression indicates STEMI.
- New left bundle branch block: New LBBB is treated as an MI equivalent.
- Q waves in the inferior leads: Inferior Q waves indicate infarction.
5. A man treated for TB pericarditis a year ago has rising JVP that increases on inspiration, ascites, oedema and a pericardial knock. CT shows a thickened calcified pericardium. What is the treatment?
Answer: Pericardiectomy. Constrictive pericarditis (TB is the leading cause in Pakistan; also post-surgery, radiotherapy, viral): rigid pericardium restricts diastolic filling — raised JVP with Kussmaul sign (rise on inspiration), prominent y descent, pericardial knock, ascites/hepatomegaly out of proportion to oedema, pulsus paradoxus less common. CT/MRI show thickened (± calcified) pericardium. Treatment: surgical pericardiectomy; anti-TB therapy reduces constriction in TB pericarditis.
- Long-term diuretics alone: Diuretics are palliative only.
- Pericardiocentesis: There is no effusion to drain.
- Heart transplant: Transplant is not needed.
6. A man has painful swallowing. Endoscopy shows white plaques in the oesophagus; biopsy shows budding yeasts and pseudohyphae. What is the organism and the usual underlying problem?
Answer: Candida, with immunosuppression. Candida oesophagitis presents with white plaques and odynophagia. Pseudohyphae and budding yeasts confirm Candida. It occurs in HIV, diabetes, steroid use (including inhaled steroids) and after antibiotics. Treat with fluconazole.
- Herpes simplex, with reflux: HSV causes small punched-out ulcers with multinucleated giant cells.
- Cytomegalovirus, with smoking: CMV causes large shallow ulcers with intranuclear inclusions.
- Aspergillus, with asthma: Aspergillus has septate hyphae and rarely affects the oesophagus.
- Cryptococcus, with diabetes: Cryptococcus has a capsule and no pseudohyphae.
7. A man with long-standing reflux has velvety red mucosa in the lower oesophagus. Biopsy shows columnar epithelium with goblet cells. What is the main risk?
Answer: Adenocarcinoma of the oesophagus. Barrett's oesophagus is intestinal metaplasia: acid reflux replaces the normal squamous epithelium with columnar epithelium containing goblet cells. It can progress through dysplasia to adenocarcinoma of the lower oesophagus. It needs surveillance endoscopy.
- Squamous cell carcinoma of the oesophagus: Linked to smoking, alcohol and hot drinks; upper and middle oesophagus.
- Achalasia: A motility disorder.
- Oesophageal varices: Caused by portal hypertension.
- Mallory–Weiss tear: Caused by forceful vomiting.
References and dose sources
- Aspirin dosing: Drugs.com: Aspirin dosage (see also our aspirin dose page)
- Glyceryl trinitrate (GTN) dosing: Drugs.com: Nitroglycerin dosage (see also our glyceryl trinitrate (gtn) dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Ondansetron dosing: Drugs.com: Ondansetron dosage (see also our ondansetron dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.