Emergency Medicine Emergency Medicine · High Yield

Causes of Chest Pain

Chest pain has a broad differential — life-threatening causes must be excluded first. A systematic approach using the mnemonic CARDIAC RAMPS organises the complete differential.

✦ The Mnemonic

"CARDIAC RAMPS Covers Every Chest Pain"

Coronary · Aortic dissection · Respiratory (PE/pneumothorax) · Digestive · Inflammatory/cardiac · Anxiety · Chest wall · Referred/other · Atypical · Musculoskeletal · Pericarditis · Spasm (oesophageal)

C Coronary (ACS) STEMI, NSTEMI, unstable angina — heavy central chest pain, radiation to jaw/left arm

A Aortic Dissection Tearing interscapular pain; anterior = Type A; posterior = Type B; hypertension key risk

R Respiratory — PE Pleuritic pain; haemoptysis; dyspnoea; Wells score; CTPA gold standard

D Digestive — GORD/oesophageal Burning retrosternal; worse lying flat; relieved by antacids

I Inflammatory — Pericarditis Sharp; pleuritic; relieved sitting forward; pericardial rub; saddle-shaped ST elevation

A Anxiety / Panic attack Atypical; hyperventilation; younger patients; reproduce with hyperventilation

C Chest wall / Costochondritis Reproducible on palpation — this is key; Tietze's if swelling

R Referred pain From subphrenic abscess, cholecystitis (right shoulder tip)

M Musculoskeletal Rib fracture; muscle strain — history of trauma, tender on palpation

P Pneumothorax Sudden pleuritic pain + dyspnoea; reduced breath sounds; tracheal deviation (tension)

S Spasm (oesophageal) May mimic ACS exactly; relieved by nitrates (adds diagnostic confusion); exclude cardiac first

📚 Clinical Breakdown

The immediate priority is to exclude the 'PTED' life threats: Pulmonary embolism, Tension pneumothorax, aortic dissEction (or ACS), and tamponaDE. These require immediate investigation and intervention.

Features suggesting ACS: central crushing pain, radiation to left arm/jaw, diaphoresis, nausea, relief with GTN. Features suggesting dissection: tearing/ripping pain, maximal at onset, migrating, inter-scapular, pulse deficit, BP differential between arms (>20 mmHg), mediastinal widening on CXR.

ECG changes by cause: ACS — ST elevation/depression; PE — S1Q3T3, sinus tachycardia, RBBB; pericarditis — saddle-shaped ST elevation in all leads (no reciprocal changes); Brugada pattern — coved-type ST in V1–V2.

Immediate life threats ACS, Aortic dissection, PE, Tension pneumothorax, Tamponade

Dissection BP difference >20 mmHg between arms

Pericarditis ECG Saddle ST elevation; PR depression; no reciprocal changes

Costochondritis key feature Reproducible on sternal/costal palpation

⭐ Clinical Pearl

High-sensitivity troponin (hs-cTnI or hs-cTnT) has transformed ACS assessment. The 0h/3h or 0h/1h protocol rapidly rules in or rules out NSTEMI with >99% NPV. A rising or falling pattern (delta troponin) distinguishes acute myocardial injury from chronic elevation. Remember: troponin is also raised in PE, myocarditis, renal failure, and sepsis — clinical context is essential.

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