Chart — Cardiac
Chest Pain Differential Chart
Side-by-side comparison of six major chest pain etiologies — ACS, pulmonary embolism, aortic dissection, GERD, musculoskeletal pain, and pericarditis — organized by pain characteristics, associated findings, distinguishing features, and urgency.
Educational use only. All chest pain requires clinical assessment and provider evaluation. This chart supports learning and NCLEX preparation — never use to delay emergency evaluation. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Chest Pain Differential Comparison
| Condition | Pain Characteristics | Associated Findings | Urgency |
|---|---|---|---|
| Acute Coronary Syndrome (ACS) | Pressure, squeezing, heaviness, or tightness — substernal; radiates to left arm, jaw, back, or epigastrium; onset at rest (UA/NSTEMI/STEMI) or with exertion (stable angina) | Diaphoresis, dyspnea, nausea, vomiting, syncope; pallor; ST changes on ECG; troponin elevation (NSTEMI/STEMI) | IMMEDIATE |
| Pulmonary Embolism (PE) | Pleuritic — sharp, localized, worsened by deep breathing or coughing; may be sudden in onset; can be dull if large central PE | Dyspnea (most common), tachycardia, tachypnea; unilateral leg swelling/DVT; hemoptysis; decreased SpO₂; S1Q3T3 or sinus tachycardia on ECG; elevated D-dimer | IMMEDIATE |
| Aortic Dissection | Sudden, severe — described as 'tearing' or 'ripping'; radiates to the back between the shoulder blades; 10/10 in severity from onset; migrates as dissection progresses | Unequal blood pressure between arms (>20 mmHg difference); new aortic regurgitation murmur; pulse deficits; neurological deficits; hypertension (most have HTN history); widened mediastinum on chest X-ray | IMMEDIATE |
| GERD / Esophageal | Burning, substernal; may radiate to throat or jaw; often worse after meals, lying flat, or bending forward; can mimic cardiac pain in quality | Regurgitation, sour taste, belching; worsened after fatty foods, caffeine, alcohol; may be chronic; esophageal spasm can cause severe squeezing pain that mimics ACS | Non-emergent |
| Musculoskeletal Pain | Sharp, localized; reproducible with palpation or movement; worsened with specific arm movements, deep breathing, or positional changes; often unilateral | Point tenderness on palpation of chest wall; history of trauma, heavy lifting, or overuse; costochondritis tenderness at costochondral junctions; no radiation to arm or jaw | Non-emergent |
| Pericarditis | Sharp, pleuritic (worsened by deep breathing, coughing, lying flat); RELIEVED by sitting up and leaning forward (classic); may radiate to left shoulder or trapezius | Pericardial friction rub (scratchy, to-and-fro — heard best at left sternal border with patient leaning forward); diffuse concave ('saddle-shaped') ST elevation on ECG; PR depression; fever possible (if infectious) | Urgent (not immediately life-threatening unless tamponade present) |
Key Distinguishing Features by Condition
Key differentiator: Diaphoresis is highly specific; relieved by NTG (partially in ACS); not worsened by palpation; onset relationship to exertion or rest
Key action: 12-lead ECG within 10 minutes; aspirin; IV access; notify provider immediately
Key differentiator: Pleuritic (breathing worsens it) + sudden dyspnea + DVT risk factors + hemoptysis; Wells score for PE probability; CT-PA confirms
Key action: Supplemental O₂; IV access; stat CT-PA; anticoagulation per order; notify provider immediately
Key differentiator: Tearing/ripping quality is highly specific; radiating to back; unequal arm BPs; absence of ST elevation (unless dissection involves coronary ostia)
Key action: Check bilateral BPs; CT aortogram emergently; blood pressure control (labetalol, nitroprusside); surgical consultation; do NOT give thrombolytics
Key differentiator: Relieved by antacids or PPI; associated with food intake; no diaphoresis; ECG normal; troponin normal; worsened lying flat and after meals
Key action: Rule out cardiac cause first; ECG and troponin if any doubt; antacids may provide diagnostic relief; GI follow-up
Key differentiator: Reproducible with palpation — most reliable differentiator from cardiac pain; localized; worsened by movement/position; normal ECG and troponin
Key action: Rule out cardiac cause; assess for palpation reproducibility; NSAIDs for treatment if confirmed musculoskeletal origin
Key differentiator: Positional change (leaning forward relieves) is a classic NCLEX feature; pericardial friction rub; diffuse (not territorial) ECG changes; no troponin rise (unless myopericarditis); younger patients common
Key action: NSAIDs + colchicine for treatment; echocardiogram to rule out pericardial effusion/tamponade; check for Becks Triad if effusion suspected (hypotension, muffled sounds, JVD)
Immediate Red Flags — Escalate Now
- !ST elevation on ECG → STEMI — activate cath lab immediately
- !Tearing/ripping chest pain radiating to back → aortic dissection — no thrombolytics; check bilateral BPs
- !Sudden dyspnea + pleuritic pain + DVT symptoms → PE — CT-PA emergently
- !Pulsus paradoxus + muffled heart sounds + JVD → cardiac tamponade — emergent pericardiocentesis
- !Hypotension + chest pain (any etiology) → cardiogenic shock or obstructive shock — immediate escalation
- !Syncope with chest pain → hemodynamic compromise — do not leave patient; continuous monitoring
- !Unequal blood pressure between arms → aortic dissection until proven otherwise
NCLEX Pearls
- ›Pericarditis pain IMPROVES with leaning forward — classic NCLEX feature (sitting up reduces pressure on pericardium).
- ›Aortic dissection: tearing/ripping pain + unequal arm BPs = classic presentation; do NOT give thrombolytics.
- ›PE: pleuritic pain + sudden dyspnea + DVT risk factors + hemoptysis — S1Q3T3 on ECG.
- ›Musculoskeletal: chest wall tenderness reproducible by palpation — most reliable differentiator from cardiac cause.
- ›GERD: burning quality, worse after meals and lying flat, relieved by antacids — but rule out cardiac first.
- ›Diaphoresis with chest pain is a major cardiac red flag — highly associated with myocardial ischemia.
- ›Always get a 12-lead ECG first for any chest pain — 10-minute goal for ACS identification.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with AHA / ACC Chest Pain Guidelines. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →