Chest pain history: questions to ask and red flags

Start with an open question and let the patient describe the pain. Then fill in the details, using OPQRST or SOCRATES so nothing is missed:

• Onset: "When did it start, and what were you doing at the time?" Sudden onset at rest points away from exertional angina and toward dissection, pulmonary embolism or pneumothorax.
• Location and radiation: "Can you point to where it hurts? Does it spread anywhere?" Ischemic pain spreads to the arm, jaw or neck; dissection to the back, between the shoulder blades.
• Character: "How would you describe it?" Pressure, tightness or heaviness suggests ischemia; sharp pain worse on breathing in suggests the pleura or pericardium; tearing suggests dissection; burning suggests reflux.
• Severity and timing: how bad it is from 0 to 10, how long it lasts, whether it comes and goes, and whether it is getting worse.
• Aggravating and relieving factors: exertion and rest, breathing, position, eating, antacids, pressing on the chest wall.

• Shortness of breath, sweating, nausea or vomiting
• Palpitations, lightheadedness or fainting
• Cough, fever, sputum or coughing up blood
• Calf pain or leg swelling
• Acid taste, difficulty swallowing, or pain after vomiting

Acute coronary syndrome

Central pressure or tightness, often radiating to the arm, jaw or neck, with sweating, nausea or breathlessness. Stable angina comes on with exertion and settles with rest within minutes; pain at rest, or lasting more than 20 minutes, suggests an acute coronary syndrome. Older patients, women and people with diabetes more often present without classic pain.

Aortic dissection

Sudden, severe, tearing or ripping pain, maximal at onset, often radiating to the back. Ask about hypertension, known aortic disease, and connective tissue disease such as Marfan syndrome.

Pulmonary embolism

Pleuritic pain with sudden breathlessness, sometimes with coughing up blood or fainting. Ask about risk factors: recent surgery or immobility, long-distance travel, cancer, previous clots, pregnancy, and estrogen-containing medication.

Pericarditis

Sharp central pain, worse lying flat and on breathing in, eased by sitting forward. It often follows a viral illness.

Pneumothorax

Sudden one-sided pleuritic pain with breathlessness, classically in a tall, thin young man, a smoker, or someone with lung disease.

Gastroesophageal reflux

Burning pain behind the breastbone, related to meals or lying down, with an acid taste, eased by antacids.

Musculoskeletal pain

Localized pain, reproduced by pressing on the chest wall, worse with movement, often after strain or injury.

• Cardiovascular risk: smoking, hypertension, diabetes, high cholesterol, and heart disease in a first-degree relative at a young age
• Previous heart disease: angina, heart attacks, stents or bypass surgery
• Clotting risk: previous deep vein thrombosis or pulmonary embolism, cancer, recent surgery or travel
• Medications, including any recently started
• Cocaine and other stimulant use, which can cause ischemia and dissection at any age

Any of these needs urgent assessment, not a complete history first:

• Pain at rest lasting more than 20 minutes, especially with sweating or nausea
• Sudden tearing pain radiating to the back
• Chest pain with fainting or severe breathlessness
• Coughing up blood with sudden pleuritic pain
• Severe pain after forceful vomiting

• Assuming a young patient's pain is not cardiac without asking about cocaine use or family history.
• Forgetting that relief with antacids or nitroglycerin does not reliably separate cardiac from esophageal pain.
• Not asking about clotting risk factors, which are the main clue to pulmonary embolism.
• Not asking what the patient fears it is. Many are worried about a heart attack, and saying so changes how they hear what you say next.