Chest pain accounts for approximately six million annual visits to emergency departments (ED) in the United States, making chest pain the second most common complaint [1] . It is the second most common reason to present to the emergency department in the United States accounting for 5% to 20% of all ED admissions. Causes of chest pain range from musculoskeletal and gastrointestinal causes to life threatening conditions such as acute myocardial infarction, aortic dissection and pulmonary embolism [2] . Early risk stratification and identifying life threatening conditions are life-saving, at the same time inappropriate admissions are a burden to the health care system with tremendous costs. Accurate identification of these life-threatening and serious causes of chest pain must be accomplished without over testing and over treating patients with less serious causes [3] .

The causes of chest pain and their magnitude vary among different countries and across institutions. Musculoskeletal and chest wall conditions were the most common conditions of chest pain at primary setting in the Unites States, Germany, and Switzerland accounting for 36.2%, 46.6%, and 48.7% respectively [4] . Considerable variation exists across U.S. hospitals in ED admission rates for patients with chest pain, with admission rates ranging from 38 to 81% [5] . There is limited data available on the common causes of chest pain and admission rates at the emergency department in our institution. The aim of this study was to determine the most common causes of chest pain in the ED and to determine which patients are likely to be admitted vs. discharged home from the ED.

Of the total 497 patients included in the study, 254 (50.4%) were males and 243 (48.2%) were females. The predominant age group was 45 - 65 years, accounting for 41.1% of the total patients. A total of 358 (71%) patients with acute chest pain were evaluated, treated, and discharged from the emergency department, while 123 (24.4%) were admitted for further evaluation and inpatient management ( Figure 1 ).

The most common causes of chest pain were of musculoskeletal (MSS) origin (252, 50.0%), followed by gastrointestinal (GI) causes (58, 11.5%). These findings align with previous studies, which estimated approximately one-third to one-half of patients presenting with MSS pain, 10% - 20% with GI causes, 10% with stable angina, 5% with pulmonary conditions, and 2% - 4% with acute myocardial infarction [6] [8] . While other studies have cited GI causes as the leading etiology [9] , the predominance of MSS pain in our study may reflect specific intrinsic characteristics of our population that warrant further investigation.

Cardiovascular diseases were identified in 45 (8.9%) patients, while 53 (10.5%) had pulmonary diseases. Acute coronary syndrome (ACS), encompassing both unstable angina and myocardial infarction, represented 48 (9.5%) of all cases ( Figure 2 ). When stratified by age and sex ( Table 1 ), musculoskeletal chest pain was the most frequent cause across all age groups and in both sexes, with statistically significant associations (p = 0.012 and <0.05, respectively).

ACS: acute coronary syndrome; CVS: Cardiovascular; GI: Gastrointestinal; MSS: Musculoskeletal; Pulmonary.

Acute coronary syndrome and cardiovascular causes were more prevalent in older adults, particularly those aged 45 - 65 and 65 - 85, reinforcing the known correlation between age and increased cardiovascular risk. GI causes were notably common among the 25 - 65 age range, especially in females, indicating potential sex-specific trends in chest pain etiology. Pulmonary causes were more common in the older population (65 - 85 years), but were also present in younger groups, highlighting the broad differential diagnoses required across age ranges.

Regarding ED disposition ( Table 2 ), of the 123 admitted patients, 80 (65%) were admitted to the telemetry unit, 28 (23%) to regular floors, 6 (5%) directly to the coronary care unit (CCU), and 9 (7%) to the stroke unit. Patients diagnosed with ACS and cardiovascular conditions were significantly more likely to be admitted, whereas those with MSS pain were predominantly discharged. This reflects appropriate clinical prioritization of high-risk conditions. Furthermore, current literature suggests improved outcomes for acute MI management in institutions with Society of Chest Pain Centers-certified units [10] , which highlights the importance of specialized care units. On the other hand, successfully implementing expert consensus for low-risk chest pain will reduce Emergency Department crowding and minimize unnecessary testing [11] .

ACS: acute coronary syndrome; GI: Gastrointestinal; MSS: Musculoskeletal.

This study provides a baseline for understanding chest pain presentations in a single, urban Level 1 trauma center. The high rate of discharge for patients with MSS and GI causes supports the effectiveness of ED triage in identifying low-risk cases. However, the significant proportion of serious conditions such as ACS and pulmonary diseases underscores the need for vigilant evaluation protocols. Early recognition of clinical predictors associated with high-risk presentations could enhance triage accuracy, reduce unnecessary admissions, and improve outcomes. Establishing dedicated chest pain units may further optimize patient management and ED resource utilization.

We acknowledge Dr. Geoffrey Doughlin for providing us with de-identified raw data for the month of March 2017 of patients who visited the Emergency Department with chest pain.