How can I build a practical chest-pain differential framework for the ER?

[JacobL]

I'm a third-year medical student currently on my internal medicine rotation, and I'm struggling to systematically approach the differential diagnosis for chest pain in the ER. I understand the major life-threatening causes, but I find it challenging to confidently rule out less common etiologies and to know when to order which specific tests beyond the standard ECG and troponins. For residents or practicing physicians, what is your mental framework or checklist when a patient presents with atypical chest pain? How do you effectively differentiate between, say, costochondritis, esophageal spasm, and early pericarditis when the presentation is vague? I'm also looking for resources on interpreting subtle ECG findings that might point towards a non-STEMI ACS.

[Donald_G]

Here’s a practical, clinician-friendly framework you can apply at the bedside. Start with the big five priorities: 1) rule out immediately life-threatening causes (ACS, aortic dissection, massive PE, tension pneumothorax) with vital signs, ECG, and troponin; 2) risk-stratify for ACS using a validated tool (HEART score or TIMI) to decide observation vs admission vs discharge with follow-up; 3) perform a focused history and exam to separate chest wall pain from visceral causes (palpation for reproducible chest wall tenderness, character and timing of pain, radiation, and associated symptoms); 4) acquire targeted testing based on pre-test probability (CXR to screen for pulmonary disease/mediastinal process, echocardiography if pericarditis/myocarditis or LV dysfunction, CT angiography when PE or dissection is a possibility); 5) arrange serial testing (repeat ECG and troponin at 3–6 hours or per local protocol) and early follow-up. This helps you avoid over-testing and still catch ACS early.