[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Chest pain: ischemic, pericardial, pleural and other patterns [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # 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](https://durgical.com/en/anatomy/pericardium/) · [Left main coronary artery](https://durgical.com/en/anatomy/left-coronary-artery/) · [Right coronary artery](https://durgical.com/en/anatomy/right-coronary-artery/) · [Thoracic aorta](https://durgical.com/en/anatomy/thoracic-aorta/) · [Sternum](https://durgical.com/en/anatomy/sternum/) ## Key points - Rule out first: acute coronary syndrome, aortic dissection, embolism, tension pneumothorax, tamponade, esophageal rupture. - Pressing, exertional, radiating to arm or jaw = ischemic. - Better sitting forward, with a rub = pericardial. - Tearing to the back with a pulse difference = aortic dissection. - 12-lead ECG on arrival. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/chest-pain-ischemic-pericardial-pleural-and-other-patterns/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Pericardium](https://durgical.com/en/anatomy/pericardium/) - [Left main coronary artery](https://durgical.com/en/anatomy/left-coronary-artery/) - [Right coronary artery](https://durgical.com/en/anatomy/right-coronary-artery/) - [Thoracic aorta](https://durgical.com/en/anatomy/thoracic-aorta/) - [Sternum](https://durgical.com/en/anatomy/sternum/) ## Related - [Cardiac tamponade: Beck triad and pulsus paradoxus](https://durgical.com/en/clinical-exam/cardiac-tamponade-beck-triad-and-pulsus-paradoxus/) - [Abnormal pulses: paradoxus, alternans, parvus et tardus, bounding](https://durgical.com/en/clinical-exam/abnormal-pulses-paradoxus-alternans-parvus-et-tardus-bounding/) - [Peripheral pulses and the ankle–brachial index](https://durgical.com/en/clinical-exam/peripheral-pulses-and-the-ankle-brachial-index/) - [Signs of deep vein thrombosis: Homans and the Wells score](https://durgical.com/en/clinical-exam/signs-of-deep-vein-thrombosis-homans-and-the-wells-score/) - [Chief complaint and history of present illness](https://durgical.com/en/clinical-exam/chief-complaint-and-history-of-present-illness/) - [Adventitious sounds: crackles, wheezes, rhonchi, stridor and pleural rub](https://durgical.com/en/clinical-exam/adventitious-sounds-crackles-wheezes-rhonchi-stridor-and-pleural-rub/) ## Related conditions - [Myocardial Infarction (Heart Attack)](https://durgical.com/en/conditions/myocardial-infarction/) - [Stable angina](https://durgical.com/en/conditions/stable-angina/) - [Acute pericarditis](https://durgical.com/en/conditions/acute-pericarditis/) - [Aortic dissection](https://durgical.com/en/conditions/aortic-dissection/) - [Pulmonary embolism](https://durgical.com/en/conditions/pulmonary-embolism/) - [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/) [← All of the clinical exam](https://durgical.com/en/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](https://medlineplus.gov/ency/article/003079.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [Pericarditis: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000182.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [Aortic stenosis: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000178.htm) (MedlinePlus, U.S. National Library of Medicine, 2026). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/chest-pain-ischemic-pericardial-pleural-and-other-patterns/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/chest-pain-ischemic-pericardial-pleural-and-other-patterns/