Five killers to exclude in every chest pain: heart, aorta, lungs, pneumothorax, and esophagus.
Acute coronary syndrome / STEMI
An ECG within 10 minutes drives every next decision.
Aortic dissection
Tearing pain radiating to the back + interarm BP difference.
Pulmonary embolism
Pleuritic pain + hypoxia + thrombotic risk factors.
Tension pneumothorax
Clinical diagnosis — decompress immediately.
Esophageal rupture
Pain after violent vomiting + subcutaneous emphysema.
Pain peaking within seconds points to dissection or pneumothorax — not usually to ACS.
One normal ECG excludes nothing: repeat with every symptom change.
Prehospital ECG when possible, with hospital pre-alert for STEMI.
Exertional crushing pain, cardiac risk factors, ECG changes.
Tearing migrating pain, BP differential, widened mediastinum.
Pleuritic pain relieved leaning forward, diffuse ST elevation.
GI history or palpation-reproduced pain — a diagnosis of exclusion.
Clinical pearl
Department rule: every chest pain is coronary until proven otherwise, and every normal ECG earns a repeat — not reassurance.
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This content is an educational reference and does not replace clinical judgement or local protocols.
