Chest pain: a case-based approach to the acute assessment

The presentation

A 58-year-old man describes a heavy, central chest pressure that came on 40 minutes ago while walking, radiating to his left arm, with sweating and mild breathlessness. He has high blood pressure and smokes. Straight away, several features raise concern: the character (pressure rather than sharp), the radiation, the associated sweating and breathlessness, and his cardiovascular risk factors. In real practice this combination triggers an immediate, structured assessment rather than a wait-and-see approach.

The must-not-miss causes

Before anything else, the assessment is built around excluding the life-threatening causes of chest pain: acute coronary syndrome (heart attack and unstable angina), pulmonary embolism (a clot on the lung), aortic dissection (a tear in the main artery), tension pneumothorax (a collapsed lung under pressure), and oesophageal rupture. Each has a pattern. Tearing pain radiating to the back suggests dissection; sudden breathlessness with pleuritic (sharp, breathing-related) pain and risk factors suggests embolism; exertional pressure relieved by rest points toward cardiac ischaemia. The history is doing most of the diagnostic work here.

First tests that change management

Two investigations are done urgently. A 12-lead ECG can show ST-elevation, which would mean a major heart attack needing immediate reperfusion (opening the blocked artery). A high-sensitivity troponin blood test detects heart-muscle injury; a single value plus a repeat a few hours later helps rule a heart attack in or out. Observations — heart rate, blood pressure in both arms, oxygen saturation — and a focused examination screen for dissection and pneumothorax. The point of these early tests is not to label the pain but to decide who needs emergency treatment now.

Working through the result

In this case the ECG shows ST-depression and T-wave changes rather than ST-elevation, and the troponin is raised and rising. That pattern fits a non-ST-elevation acute coronary syndrome (NSTEMI): the heart muscle is being injured by a critically narrowed, not fully blocked, artery. Management follows established acute-coronary pathways — pain relief, antiplatelet and anticoagulant medicines, and risk assessment to decide the timing of angiography. Scores such as the GRACE score help estimate risk and guide how urgently invasive assessment is needed.

What the case teaches

The lesson is the discipline of the approach, not the specific diagnosis. Chest pain is assessed by first asking "could this kill him in the next hour?" and structuring the history, examination and first tests around that question. A benign-sounding story with reassuring tests can be watched; a concerning story is investigated even when the first ECG looks unremarkable, because early ischaemia can be subtle. Safety-netting — clear advice on what to do if symptoms change — matters as much as the initial label.