Chest pain electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]


The key findings to look for on an ECG is the ST elevation which is characteristic of myocardial infarction. However, The major challenge is the differential between NSTE-ACS and non-cardiac chest pain. Diffuse ST elevation may point to the diagnosis of pericarditis. A serial ECG should be obtained to evaluate for continued or progression of myocardial injury over time.


2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/ SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[1]

Class I
"1 In patients presented with chest pain and non diagnostic ECG, performing serial ECG is recommended, especially in patients with high clinical suspicion of ACS, persistent symptoms, or clinical condition deterioration, . (Level of Evidence C-EO)"
Class I
"2 In patients with chest pain and evidence of ischemia on ECG, treatment should be done based on the guideline of STEMI, NSTE-ACS (Level of Evidence C-EO)"
Class IIa
"3 In patients with chest pain and nondiagnostic ECG and evidence of intermediate to high clinical suspicion of ACS, leads V7-V9 should be taken for evaluation of posterior STEMI (Level of Evidence B-NR)"

An electrocardiogram is usually required for the initial evaluation of chest pain. It is very useful for the diagnosis of several etiologies of chest pain such as:

Acute coronary syndrome

  • A standard 12 lead ECG is recommended in all patients with chest pain within 10 minutes of presentation if acute coronary syndrome is suspected. [2][3]
  • Findings on an ECG suggestive of ACS include [4][5], ST elevation, ST depression and a new left bundle branch block (LBBB)
  • It is important to note that a normal ECG does not rule out the presence of an acute myocardial infarction as an ECG can show a hyper-acute T wave [6][7] [8] as an early presentation.
  • If an initial ECG is non-diagnostic and there is still a high clinical suspicion of an MI, a repeat ECG should be conducted.
  • It is helpful to have precious ECGs of a patient to determine if observed findings are new.

Shown below is an ECG demonstrating clear ST elevation in the right precordial leads depicting STEMI. A coronary angiography revealed a proximal right coronary artery occlusion. [9]


For more ECG examples of ST elevation myocardial infarction click here


  • ECG findings in patients with pericarditis may mirror that seen in acute myocardial infarction and carrying changes may be seen as the disease progresses.
  • Findings on an ECG suggestive of pericarditis at different levels include: [11]
  • Stage I: ST elevation in all leads; PTa depression (depression between the end of the P wave and the beginning of the QRS complex)
  • Stage II: Pseudonormalization (transition)
  • Stage III: Inverted T waves
  • Stage IV: Normalization

Acute aortic dissection

Exercise ECG


There are conditions that may render the exercise ECG useless for assessing acute coronary syndromes such as:

  • Abnormal ST changes on resting ECG;
  • Digoxin;
  • Left bundle branch block;
  • Wolff-Parkinson-White pattern;
  • Ventricular paced rhythm (not useful for establishing ischemia);
  • Unable to achieve ≥5 METs or unsafe to exercise;
  • High-risk unstable angina or acute myocardial ischemia;
  • Uncontrolled heart failure;
  • Significant cardiac arrhythmias or high risk for arrhythmias caused by QT prolongation;
  • Severe aortic stenosis;
  • Severe hypertension (eg, ≥200/110mmHg);
  • Acute illness.[15]


  1. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).
  2. Slater DK, Hlatky MA, Mark DB, Harrell FE, Pryor DB, Califf RM (October 1987). "Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic findings". Am. J. Cardiol. 60 (10): 766–70. doi:10.1016/0002-9149(87)91020-4. PMID 3661390.
  3. Brush JE, Brand DA, Acampora D, Chalmer B, Wackers FJ (May 1985). "Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction". N. Engl. J. Med. 312 (18): 1137–41. doi:10.1056/NEJM198505023121801. PMID 3920520.
  4. Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (January 1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients". Arch. Intern. Med. 145 (1): 65–9. PMID 3970650.
  5. O'Gara, Patrick T.; Kushner, Frederick G.; Ascheim, Deborah D.; Casey, Donald E.; Chung, Mina K.; de Lemos, James A.; Ettinger, Steven M.; Fang, James C.; Fesmire, Francis M.; Franklin, Barry A.; Granger, Christopher B.; Krumholz, Harlan M.; Linderbaum, Jane A.; Morrow, David A.; Newby, L. Kristin; Ornato, Joseph P.; Ou, Narith; Radford, Martha J.; Tamis-Holland, Jacqueline E.; Tommaso, Carl L.; Tracy, Cynthia M.; Woo, Y. Joseph; Zhao, David X. (2013). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction". Journal of the American College of Cardiology. 61 (4): e78–e140. doi:10.1016/j.jacc.2012.11.019. ISSN 0735-1097.
  6. Somers MP, Brady WJ, Perron AD, Mattu A (2002). "The prominant T wave: electrocardiographic differential diagnosis". Am J Emerg Med. 20 (3): 243–51. PMID 11992348. Unknown parameter |month= ignored (help)
  7. Smith SW, Whitwam W. "Acute Coronary Syndromes." Emerg Med Clin N Am 2006; 24(1): 53-89. PMID 16308113
  8. "The clinical value of the ECG in noncardiac conditions." Chest 2004; 125(4): 1561-76. PMID 15078775
  9. "ST elevation myocardial infarction electrocardiogram - wikidoc".
  11. "Pericarditis electrocardiogram - wikidoc".
  13. Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
  14. Hirata, Kazuhito; Wake, Minoru; Kyushima, Masahiro; Takahashi, Takanori; Nakazato, Jun; Mototake, Hidemitsu; Tengan, Toshiho; Yasumoto, Hiroshi; Henzan, Eisei; Maeshiro, Masao; Asato, Hiroaki (2010). "Electrocardiographic changes in patients with type A acute aortic dissection". Journal of Cardiology. 56 (2): 147–153. doi:10.1016/j.jjcc.2010.03.007. ISSN 0914-5087.
  15. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK; et al. (2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001030. PMID 34709928 Check |pmid= value (help).