Chest pain
Four killers first — ACS, aortic dissection, PE, tamponade — then the structural causes.
Echo approach, step by step
Echo during or soon after pain answers four time-critical questions: is there ischaemia, and is there an aortic, pulmonary-embolic or pericardial catastrophe? It then looks for structural causes [195]. A new regional wall-motion abnormality supports ischaemia. Normal wall motion during ongoing pain makes significant ischaemia less likely but does not exclude it [138,195].
- Subcostal / PLAX — first 60 secondsLook for pericardial effusion and signs of tamponade, gross LV function and RV size.
- Apical 4, 2, 3 + PSAXScore regional wall motion in 17 segments and name the coronary territory. Use contrast if two or more segments are not seen [1].
- Mechanical complicationsIf the infarct is not new, look for a septal colour jet (VSD), flail mitral leaflet (papillary rupture) and an effusion after MI (rupture) [138].
- AortaMeasure the root and ascending aorta, and look for a flap and aortic regurgitation. View the arch from the suprasternal notch [9,173].
- Right heartLook for RV/LV >1.0, the McConnell sign, septal flattening, TR gradient and the 60/60 sign → PE [124,147,148].
- PericardiumEffusion with pleuritic pain or rub → pericarditis or myopericarditis [125].
- Structural causesAS (calcified valve, Vmax), HCM with LVOT obstruction, takotsubo pattern [5,13,133].
- LungsLung sliding (pneumothorax), B-lines and consolidation [199].
- Effusion / tamponade
- Regional wall motion and territory
- LVEF
- Aortic root, flap, AR
- RV size and function
- Valves and LVOT
- Lung sliding
Causes & echo clues
| Cause | What echo shows | Confirm with |
|---|---|---|
| Acute coronary syndrome | New RWMA in a coronary territory; mechanical complications | ECG, hs-troponin, angiography [138] |
| Aortic dissection | Flap, dilated root, AR, effusion; RWMA if a coronary is involved | CT angiography, TOE [9,173] |
| Pulmonary embolism | RV dilatation, McConnell, 60/60, D-shaped LV, thrombus in transit | CT pulmonary angiography [124] |
| Pericarditis / myopericarditis | Effusion (often absent); regional or global dysfunction if myocarditis | ECG, CRP, troponin, CMR [125] |
| Tamponade | Effusion with collapse and respiratory Doppler variation | Clinical findings, drainage [149] |
| Takotsubo | Wall motion abnormality beyond one coronary territory | Angiography, recovery [133] |
| Aortic stenosis | Calcified valve, Vmax ≥4 m/s | Echo grading [5] |
| HCM | Hypertrophy, SAM, LVOT gradient | Echo with provocation, CMR [13] |
| Pneumothorax | No lung sliding, lung point | Chest X-ray / CT [199] |
| Non-cardiac (oesophageal, musculoskeletal) | Normal echo | Clinical |
Clinical pathway to the diagnosis
- 0–10 minutes12-lead ECG within 10 minutes. ST elevation or equivalent → reperfusion pathway without waiting for echo [138,195].
- High-sensitivity troponinUse the 0/1-hour or 0/2-hour algorithm to rule in or rule out NSTEMI [138].
- Pre-test probability of the other killersADD-RS for dissection (ADD-RS ≥1 → aortic imaging) [203]. Clinical probability and D-dimer for PE (Wells or Geneva; age-adjusted D-dimer) [124].
- EchoIn the ED, use echo if ECG and troponin are non-diagnostic, the patient is unstable, a mechanical complication is suspected, or to find an alternative diagnosis [195].
- Further imagingCT angiography of the aorta or pulmonary arteries as indicated. Coronary CT angiography for intermediate-risk stable patients without known CAD [139,195].
- DispositionAdmission for ACS, dissection, PE or tamponade. Outpatient testing (stress imaging or CCTA) for low-risk patients with non-diagnostic tests [195].
Clinical pearls & pitfalls
PitfallInferior STEMI + AR murmur or pulse deficit = type A dissection involving the right coronary until proved otherwise. Look at the aortic root before antithrombotic therapy [9].
- Echo between episodes can be normal in unstable angina. A normal study does not exclude ACS [195].
- Posterior (inferolateral) MI is ECG-silent in the standard leads (ST depression V1–V3). An inferolateral wall-motion abnormality is the clue [138].
- Chest pain + syncope + hypoxaemia + dilated RV → PE. Look for thrombus in transit [124].
- Chest pain + effusion + hypotension → dissection or rupture before viral pericarditis [9,31].
- Women, older and diabetic patients often present with dyspnoea, fatigue, nausea or epigastric pain rather than typical angina [195].
- Dynamic LVOT obstruction (HCM, takotsubo, hypovolaemia) mimics ACS with shock. Nitrates and inotropes make it worse [13,134].
Red flags
- Haemodynamic instability, syncope or new heart failure
- Pulse deficit, inter-arm BP difference or new AR murmur → dissection [203]
- Hypoxaemia with a clear chest → PE [124]
- Hypotension with raised JVP → tamponade, RV infarction or PE
- ST elevation → reperfusion; do not delay for echo [138]