Chest pain: ischemic, pericardial, pleural and other patterns !

Syndrome

Not all chest pain comes from the heart, but the cardiac and life-threatening kinds must be recognized fast.

Updated 2026-11-01

See it in 3D: Pericardium · Left main coronary artery · Right coronary artery · Thoracic aorta · Sternum

What it is

Chest pain is classified by its features: quality, location, radiation, duration, triggers and relief. Life-threatening causes come first: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, tamponade and esophageal rupture.

Key findings

Ischemic: retrosternal pressure radiating to the left arm, neck or jaw, with exertion or at rest, lasting minutes; sweating, nausea, dyspnea.
Pericardial: sharp, worse lying flat and on inspiration, better sitting forward; pericardial rub.
Pleural: sharp, localized, worse with inspiration and cough (pneumonia, embolism, pneumothorax).
Aortic dissection: sudden, tearing, to the back between the scapulae; pulse or pressure difference between arms, aortic regurgitation murmur.
Esophageal: retrosternal burning, linked to meals or lying down. Chest wall: reproducible on palpation (costochondritis). Herpes zoster: in a dermatome.

Pathophysiology

Ischemic: the myocardium receives less oxygen than it needs; visceral fibers give a diffuse, pressing pain referred to the arm, neck or jaw.
Pericardial and pleural: the parietal pleura and pericardium have somatic innervation; the pain is sharp and changes with breathing or posture. The pericardium refers to the trapezius ridge via the phrenic nerve.
Aortic: a tear in the wall gives sudden, severe pain that migrates to the back.
Chest wall: muscles, ribs and cartilage; the pain is reproduced by palpation.

Common causes

Acute coronary syndrome (infarction, unstable angina) and stable angina.
Pericarditis, aortic dissection, pulmonary embolism, pneumothorax, pneumonia with pleurisy.
Gastroesophageal reflux, esophageal spasm, peptic ulcer, biliary colic.
Costochondritis, muscle strain, herpes zoster, anxiety or panic (a diagnosis of exclusion).

Tests that confirm it

A 12-lead electrocardiogram within minutes of arrival, and serial troponin.
Chest X-ray, D-dimer or CT angiography as suspicion dictates; echocardiography if effusion or dissection is suspected.
Women, people with diabetes and older adults may have ischemia with atypical symptoms (dyspnea, fatigue, epigastric pain).

Test yourself

Think of the answer, then tap the question to see it.

Which pain feature suggests pericarditis?

Sharp pain that worsens lying flat and on inspiration and eases sitting forward, sometimes with a pericardial rub.

Which exam findings suggest aortic dissection?

A pulse or blood pressure difference between the arms, an aortic regurgitation murmur and neurological deficit, with sudden tearing pain to the back.

Which patient groups may have ischemia without typical pain?

Women, people with diabetes and older adults, who may present with dyspnea, fatigue or epigastric pain.

Which test comes first for chest pain suspected to be ischemic?

A 12-lead electrocardiogram within minutes of arrival.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

← All of the clinical exam

Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: Chest pain: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); Pericarditis: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); Aortic stenosis: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026).

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Representative model, for educational purposes only.