Chest Pain in the ER and What Doctors Are Really Looking For
How Emergency Physicians Separate Heartburn From Heart Attack in Minutes
Chief Complaint What Does That Even Mean?
When someone arrives in the emergency department, the first question is simple. Why are you here? Not what are you afraid of. Not what you Googled. What symptom is bothering you the most right now? That is the chief complaint.
Chest pain is one of the most common and most serious chief complaints we see. The phrase “my chest hurts” immediately raises the level of attention in the room. It is a symptom that demands respect.
The Goal Is Safety First
The emergency department does not always provide the final answer. Sometimes it does. Sometimes that answer unfolds over time. The immediate responsibility is not perfection. It is protection.
Risk stratification is the core task. In plain language, that means separating dangerous from not dangerous. Certainty is ideal. Safety is mandatory.
The Big Dangerous Causes
When someone reports chest pain, the mind quickly scans for major threats. Heart attack. Pulmonary embolism. Aortic dissection. Pneumothorax. Severe pneumonia. These are the diagnoses that cannot be missed.
Everything else is considered after these are evaluated. The order matters. Emergency medicine prioritizes what can kill first, then what can wait.
The First Questions Matter
When did it start? Was it sudden or gradual? Is it pressure like an elephant sitting on the chest or sharp and worse when breathing? Is there shortness of breath, fever, cough, trauma, or recent travel? Age and medical history matter.
Heavy substernal pressure radiating to the left arm raises concern for myocardial infarction. Sharp pain after a long flight raises concern for pulmonary embolism. Fever and cough shift thinking toward pneumonia. Pain radiating to the back in someone with uncontrolled hypertension raises concern for aortic dissection. This is pattern recognition guided by physiology.
The Workup Is Structured
The EKG is performed early because electrical changes can reveal a heart attack within seconds. Troponin is a blood test that detects heart muscle injury. A chest X ray can show pneumonia or a collapsed lung. A D dimer may help rule out blood clots in carefully selected patients.
Sometimes observation is part of the strategy. Serial troponins, continuous cardiac monitoring, and repeat examinations allow time to clarify what a single moment cannot. Chest pain is rarely a one test diagnosis.
The Common Causes
Many cases of chest pain are not life threatening. Costochondritis is inflammation of the cartilage between the ribs and is often tender to touch. Acid reflux can cause burning discomfort that worsens when lying flat. Anxiety can produce real chest tightness, palpitations, and shortness of breath.
But reassurance comes after evaluation. No one should be told it is stress before dangerous causes are excluded. That distinction matters.
Why Some Patients Stay
If initial testing is normal but the story is concerning, further monitoring may be necessary. Heart muscle injury can evolve over hours. Rhythm abnormalities such as atrial fibrillation can cause discomfort and instability.
Sometimes the safest decision is observation. Discharging chest pain requires confidence grounded in data, not hope grounded in comfort.
The Hard Truth
Not every case ends with a perfectly labeled diagnosis. That can feel frustrating for patients and physicians alike.
But ruling out life threatening causes is a success. In emergency medicine, safety comes before certainty.
THE BOTTOM LINE
• Chest pain is one of the most common and most serious chief complaints in the ER
• The primary goal is to rule out life threatening causes such as heart attack, pulmonary embolism, aortic dissection, pneumothorax, and severe infection
• Many cases turn out to be benign, but that determination requires structured evaluation, not guesswork
Written by a Board-Certified Emergency Medicine Physician