Chest Pain Evaluation: When to Go to the Emergency Department

When your chest hurts, your brain screams heart attack. But not every ache means your heart is failing. Chest pain is one of the most common reasons people rush to the emergency department - and also one of the most misunderstood. About 6 to 8 million people in the U.S. show up with chest pain every year. Only 10 to 15% of them are having a heart attack. The rest? Anxiety, acid reflux, muscle strain, lung issues, or something else entirely. The problem isn’t just the pain - it’s knowing when to panic and when to wait.

What Chest Pain Really Looks Like

Chest pain isn’t always a sharp stab or a crushing weight. The 2021 American Heart Association guidelines define it broadly: pressure, tightness, burning, or discomfort in the chest, shoulders, arms, neck, jaw, upper back, or even the upper belly. It can come with shortness of breath, nausea, cold sweat, or sudden fatigue. These are called anginal equivalents - signs your heart might be starved for oxygen, even if you don’t feel classic chest pain.

Think about it this way: a 68-year-old woman with diabetes might not feel chest pressure at all. Instead, she feels like she’s been hit by a truck - exhausted, dizzy, nauseous. She doesn’t think it’s her heart. But that’s exactly how many heart attacks present in women, older adults, and people with diabetes. Ignoring those symptoms because they don’t match the movies can be deadly.

When You Must Go to the Emergency Department

Don’t wait. Don’t call a friend. Don’t Google it. If you’re experiencing any of these, call emergency services (000 in Australia) right away:

• Chest pain that lasts more than 10 minutes and doesn’t go away with rest or antacids
• Pain that spreads to your arm, jaw, neck, or back
• Breaking out in a cold sweat for no reason
• Shortness of breath that comes with chest discomfort
• Dizziness, fainting, or feeling like you’re about to pass out
• Nausea or vomiting with chest pressure
• Heart rate over 100 beats per minute or very low blood pressure
• Crackling sounds in your lungs or swelling in one leg

These aren’t guesses. These are red flags backed by clinical evidence. If you have any of these, your body is screaming for immediate help. Emergency medical services (EMS) can start treatment on the way - like giving you aspirin, oxygen, or a 12-lead ECG - and alert the hospital before you even arrive. Driving yourself? That increases your risk of complications by 25 to 30%.

What Happens in the Emergency Department

When you arrive, the first thing they do is check if you’re sick or not sick. That’s the clinical gut check. Are you pale? Sweating? Gasping? Is your heart racing? Are you confused? If yes - they move fast.

Within 10 minutes of arrival, you’ll get a 12-lead ECG. It’s not optional. It’s mandatory. This simple test can show if you’re having a STEMI - a full blockage in a heart artery. If it does, they activate the cath lab immediately. The goal? Get you to the angioplasty table in under 90 minutes. Every minute counts.

At the same time, they’ll draw blood for a high-sensitivity troponin test. Troponin is a protein released when heart muscle is damaged. The old tests took hours. The new ones? They can rule out a heart attack in as little as one to two hours. About 70 to 80% of chest pain patients can be safely sent home within that window - no unnecessary scans, no overnight stays.

But here’s the catch: these fast protocols only work with modern high-sensitivity troponin assays. If your hospital still uses old equipment, the timeline stretches. That’s why knowing your local hospital’s capabilities matters - especially if you’re at risk.

What They Look For Beyond the Heart

The ER team doesn’t just check for heart attacks. They rule out other life-threatening causes:

• Pulmonary embolism: A blood clot in the lung. Often presents with sudden shortness of breath and sharp, stabbing chest pain that gets worse when you breathe.
• Aortic dissection: A tear in the main artery. Pain feels like a ripping or tearing sensation, often starting in the chest and moving to the back.
• Pneumonia or pleurisy: Inflammation in the lungs or lining. Pain is sharp and worsens with breathing or coughing.
• GERD or esophageal spasm: Burning pain behind the breastbone, often after eating, relieved by antacids.
• Costochondritis: Inflammation of the rib cartilage. Pain is localized, tender to touch, and gets worse with movement.

Doctors use tools like the HEART score - a simple checklist of History, ECG, Age, Risk factors, and Troponin - to decide if you’re low, medium, or high risk. A score of 0 to 3? You’re likely safe to go home with follow-up. A score of 7 to 10? You’re going straight to the cath lab.

Why You Shouldn’t Wait or Self-Diagnose

Too many people delay because they think it’s “just gas” or “stress.” One patient in Perth told me he ignored chest pressure for three days because he was “too busy.” He ended up in the ER with a blocked artery and a 70% heart attack. He survived. But he lost months of his life recovering.

Another common mistake: taking nitroglycerin or aspirin without knowing if it’s safe. Aspirin helps if it’s a heart attack - but if it’s a bleeding ulcer or aortic tear, it could make things worse. Nitroglycerin lowers blood pressure. If your blood pressure is already low - say, from a pulmonary embolism - it can drop you into shock.

Bottom line: if you’re unsure, go. The worst-case scenario isn’t embarrassment. It’s dying because you waited.

What Happens After the Emergency

If you’re cleared of a heart attack, you still need follow-up. Many people leave the ER thinking they’re fine - but they might have INOCA (ischemia with nonobstructive coronary arteries). That’s when your heart doesn’t get enough blood, even though no artery is blocked. It’s real. It’s common. And it’s often missed.

For these patients, stress tests or cardiac MRI might be needed later. Some might need medications like beta-blockers or nitrates. Others need lifestyle changes - quitting smoking, managing blood pressure, starting cardiac rehab.

Even if you’re low risk, don’t ignore recurring symptoms. A single episode of chest pain could be a warning sign of something building. That’s why the guidelines stress shared decision-making: you and your doctor talk about risks, costs, radiation exposure from scans, and alternatives. You’re not just a case number. You’re the person who lives with the outcome.

What’s Changing in 2025

AI is starting to play a role. Early studies show algorithms can detect subtle ECG changes humans miss - like tiny ST-segment shifts that signal early ischemia. By 2025, 75% of U.S. hospitals are expected to use AI-assisted ECG interpretation. That means faster, more accurate diagnoses - especially in places with fewer specialists.

In Australia, the rollout is slower but steady. Major hospitals in Perth, Sydney, and Melbourne are already testing these tools. The goal? Cut diagnosis time by 15 to 20 minutes. That’s not just efficiency - it’s lives saved.

The 2021 AHA/ACC guidelines are still the gold standard. No major overhaul is expected until 2026. But experts agree on one thing: the future of chest pain evaluation is faster, smarter, and more personalized. And it starts with you knowing when to act.

What to Do Next

If you’ve had chest pain - even once - schedule a follow-up with your GP or a cardiologist. Don’t wait until it happens again. Ask about your HEART score, whether your hospital uses high-sensitivity troponin, and if you need further testing like a stress test or echocardiogram.

Know your risk factors: high blood pressure, high cholesterol, smoking, diabetes, family history, obesity. Even if you feel fine, managing these matters. And if you live alone or have a history of heart disease, make sure someone knows your plan - what to do, who to call, where your medications are.

Heart attacks don’t wait. Neither should you.