What is a good example of medical decision making for a patient presenting with chest pain?

From the Guidelines

A comprehensive medical decision making section for a patient with chest pain should include a clear assessment of the differential diagnosis, risk stratification, and management plan, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. This approach ensures that patients receive timely and appropriate care, reducing the risk of morbidity and mortality. Key components of the medical decision making section include:

• A thorough assessment of the patient's symptoms, medical history, and risk factors for coronary artery disease
• Use of high-sensitivity troponins to establish a biomarker diagnosis of acute myocardial infarction, as recommended by the guideline 1
• Early identification or exclusion of life-threatening causes of chest pain, such as acute coronary syndrome, pulmonary embolism, and aortic dissection
• Shared decision-making with the patient, including discussion of the risks and benefits of diagnostic testing and treatment options, as emphasized in the guideline 1
• Use of clinical decision pathways to guide the evaluation and management of patients with chest pain, as recommended by the guideline 1
• Consideration of alternative diagnoses, such as noncardiac causes of chest pain, and use of structured risk assessment to estimate the patient's risk for coronary artery disease and adverse events, as outlined in the guideline 1 For example: "Patient presents with acute chest pain concerning for possible acute coronary syndrome. ECG shows no ST elevations but has T-wave inversions in lateral leads. Initial troponin is negative. Given the patient's risk factors including hypertension, diabetes, and family history of premature CAD, I am concerned about unstable angina or NSTEMI. Will admit to telemetry for serial troponins q3h, continuous cardiac monitoring, and initiate ACS protocol including aspirin 325mg loading dose followed by 81mg daily, clopidogrel 300mg loading dose followed by 75mg daily, and atorvastatin 80mg daily. Metoprolol 25mg BID initiated for heart rate control and antianginal effect. Sublingual nitroglycerin 0.4mg PRN for breakthrough chest pain. Will order cardiology consultation for possible cardiac catheterization if troponins become positive or symptoms persist. Alternative diagnoses including pulmonary embolism, aortic dissection, and pericarditis are less likely based on clinical presentation but will remain vigilant. Will reassess after serial troponins and further workup." Some important points to consider when evaluating a patient with chest pain include:
• The use of high-sensitivity troponins to detect myocardial injury, as recommended by the guideline 1
• The importance of shared decision-making with the patient, including discussion of the risks and benefits of diagnostic testing and treatment options, as emphasized in the guideline 1
• The use of clinical decision pathways to guide the evaluation and management of patients with chest pain, as recommended by the guideline 1
• The consideration of alternative diagnoses, such as noncardiac causes of chest pain, and the use of structured risk assessment to estimate the patient's risk for coronary artery disease and adverse events, as outlined in the guideline 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medical Decision Making for Chest Pain

• The medical decision making section of a note for a patient presenting with chest pain should include an assessment of the patient's symptoms, medical history, and risk factors for acute coronary syndromes (ACS) 2, 3, 4, 5, 6.
• The note should document the results of electrocardiography (ECG) and any other diagnostic tests performed, such as high-sensitivity troponin measurements 2, 5.
• The decision to perform primary percutaneous coronary intervention (PCI) or fibrinolytic therapy should be based on the patient's ECG results and medical history 2.
• For patients with non-ST-segment elevation ACS (NSTE-ACS), the note should include an assessment of the patient's risk factors and the decision to perform invasive coronary angiography and percutaneous or surgical revascularization 2, 5.
• The note should also include a discussion of the patient's treatment plan, including any medications prescribed and any follow-up appointments or tests scheduled 2, 3, 4, 5, 6.

Diagnostic Considerations

• The differential diagnosis for chest pain is broad and includes conditions such as ACS, pulmonary embolism, and aortic dissection 3, 4, 5.
• A comprehensive history and physical examination are essential in evaluating patients with chest pain 3, 4, 5.
• The use of risk scores and diagnostic algorithms can help stratify patients according to their likelihood of having cardiac chest pain 5, 6.

Treatment Options

• The treatment of ACS depends on the patient's ECG results and medical history, and may include primary PCI, fibrinolytic therapy, or invasive coronary angiography and percutaneous or surgical revascularization 2, 5.
• The use of high-sensitivity troponin measurements and serial ECG examinations can help identify patients with NSTE-ACS 2, 5.
• Transthoracic echocardiography and computed tomography angiography may also be used to evaluate patients with chest pain 5.