<keypoints>
- **Life-threatening causes** to exclude: ACS, pulmonary embolism, aortic dissection, spontaneous pneumothorax, and oesophageal rupture
- **Key clinical red flags**: altered consciousness, syncope, dyspnoea, active/ongoing chest pain, ischaemic ECG changes, arrhythmia, hypotension, diaphoresis
- **Refer to ED urgently** if: severe or ongoing pain ≥10 min, pain at rest/minimal activity, syncope/pre-syncope, HR >120, SBP <90, RR >30, heart failure signs, ST changes, or new LBBB
- **Atypical presentations in women, elderly, and diabetics** may include fatigue, nausea, jaw/neck/back pain, dyspnoea, or indigestion without classic chest pain
</keypoints>
Life-Threatening Diagnoses Not to Miss
The primary focus in acute chest pain should be exclusion of these potentially fatal conditions:
- Acute coronary syndrome (AMI, unstable angina): by far the most common life-threatening cause
- Pulmonary embolism
- Aortic dissection
- Spontaneous pneumothorax
- Oesophageal rupture
Clinical Red Flags (NSW ACI ECAT Protocol)
Historical
- Known cardiac history
- Multiple cardiac risk factors (age >55, family history, hypertension, hyperlipidaemia, diabetes, smoking, Aboriginal and Torres Strait Islander peoples)
Clinical
- Altered level of consciousness
- Syncope
- Shortness of breath
- Active or ongoing chest pain / ischaemic symptoms
- Ischaemic ECG changes