Severe Chest Pain – Emergency, Serious Signs, Evaluation

The onset of severe chest pain often raises the concern of serious underlying pathology, even in young patients and healthy adults. Chest pain is among the more common causes of emergency room visits and in many cases, the cause is often less serious than the initial concerns of the patient. The severity of the pain differs based on the individual tolerance of a person and the underlying cause. However, a case of severe chest pain should not be ignored or attributed to benign causes – it should always be investigated by a doctor.

The presence of severe chest pain often leads the patient to question whether a trip to the emergency room is necessary or if they are “making a big deal of a little pain”. As a rule of thumb, chest pain should be investigated immediately irrespective of the possible cause or lack of concomitant signs and symptoms. Even low risk patients¬† should not ignore the pain as the possibility of other – either less serious or rare but serious conditions -¬† can be missed by assessing one’s risk based solely on age, weight, medical history and preceding events.

Is Chest Pain Serious?

Determining if the intensity of pain indicates a serious cause or not should be based on whether the pain is impairing daily functioning. If the chest pain is affecting any of the following aspects, then it should be considered as severe and warrants further investigation.

  1. Sleep. Cannot fall asleep or maintain sleep due to the intensity of the pain. Nightmares and ‘bad dreams’ may also be a result of the persistent pain.
  2. Work. Unable to attend work or complete tasks efficiently due to the chest pain.
  3. Physical activity. Apprehensive about undertaking any physical activity due to the pain or exacerbation of the pain upon activity.
  4. Mental tasks. Difficulty concentrating or completing otherwise simple mental exercises.
  5. Emotional state. Depressed and withdrawn, or agitated and irritable due to the chest pain.

Warning Signs

The presence of other signs and symptoms, especially the following should warrant an immediate trip to the emergency room.

Patients at risk of cardiac conditions should not interpret the chest pain as being “not serious” due to the absence of these warning signs and other concomitant symptoms.

Chest Pain Evaluation

At the emergency room, the attending doctor will conduct a quick assessment and request specific tests to confirm or exclude possible conditions as per his/her differential diagnosis. A patient’s cooperation and accurate reporting of the following can assist the doctor with making a prompt diagnosis.

  • Character of pain. Describe the pain – severe chest pain will only tell your doctor that the pain was unbearable enough to result in a trip to the emergency room. Is the chest pain constricting, sharp/stabbing, tight, choking , burning or dull?
  • Location. Is it localized to one part of the chest (center, right, left) or throughout the entire chest? Is it superficial (feels like it is on the outside) or deep (feels like it is inside)?
  • Radiation. Is is radiating to other parts of the body (arm, jaw, back, abdomen)?
  • Precipitating factors. What activities triggered the pain (food, activity, stress, change of position)? It may also be useful to provide a short but informative account of events that preceded the onset of the pain even if the chest pain did not appear to be triggered by these events.
  • Relieving factors. What eased the chest pain, whether partially or completely? This could be related to rest, use of certain medication, consuming certain foods or drinks, change in position.
  • Concomitant signs and symptoms. What other associated signs and symptoms appeared along with the chest pain? These signs and symptoms may no longer be evident but should be reported to the attending doctor.

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