What should be ordered for a patient experiencing shortness of breath (SOB) chest pain and palpitations?

From the Guidelines

For a patient presenting with shortness of breath (SOB), chest pain, and palpitations, I recommend ordering an electrocardiogram (ECG/EKG), complete blood count (CBC), basic metabolic panel (BMP), cardiac enzymes (troponin), chest X-ray, and arterial blood gas (ABG) or pulse oximetry, as these tests are crucial in evaluating potentially serious conditions like acute coronary syndrome, pulmonary embolism, arrhythmias, or respiratory disorders, as suggested by the 2024 American Heart Association guidelines 1.

When evaluating a patient with these symptoms, it is essential to consider the potential causes and the importance of prompt evaluation. The combination of tests allows for assessment of cardiac damage (troponin), electrical activity (ECG), oxygenation status (ABG/pulse ox), and structural abnormalities (chest X-ray), providing a comprehensive evaluation to determine the underlying cause and guide appropriate treatment.

Some key points to consider when evaluating these patients include:

• The importance of early activation of emergency medical services (EMS) for patients with chest pain or other symptoms suggestive of acute coronary syndrome, as emphasized by the 2024 American Heart Association guidelines 1.
• The use of aspirin in patients with suspected myocardial infarction, as recommended by the 2015 American Heart Association guidelines 1, with a suggested dose of 162 to 324 mg, as indicated by the 2024 American Heart Association guidelines 1.
• The potential benefits and risks of oxygen supplementation, as discussed in the 2017 British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings 1, which suggests that oxygen should be provided if oxygen saturation is low.
• The importance of continuous monitoring of vital signs and provision of supplemental oxygen if necessary, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.

Overall, the management of patients with SOB, chest pain, and palpitations requires a comprehensive approach that includes prompt evaluation, appropriate testing, and timely intervention to address potentially life-threatening conditions. The most critical step is to order the necessary tests, including ECG, troponin, and chest X-ray, to evaluate for cardiac and pulmonary causes, as recommended by the 2024 American Heart Association guidelines 1.

From the FDA Drug Label

Avoid use in patients with symptoms or signs of acute myocardial ischemia, for example, unstable angina or cardiovascular instability; these patients may be at greater risk of serious cardiovascular reactions to adenosine injection. Fatal and nonfatal cardiac arrest, sustained ventricular tachycardia (requiring resuscitation), and myocardial infarction have occurred following adenosine infusion

The patient is having sob chest pain and palpitations, which may be indicative of acute myocardial ischemia.

• Do not order adenosine (IV), as it may worsen the patient's condition and increase the risk of serious cardiovascular reactions, including cardiac arrest, ventricular arrhythmias, and myocardial infarction 2.

From the Research

Initial Assessment and Diagnostic Approach

When a patient presents with shortness of breath (SOB), chest pain, and palpitations, a thorough initial assessment is crucial. The differential diagnoses for these symptoms are broad and non-specific, as noted in the study by 3.

Diagnostic Tests and Procedures

To narrow down the differential diagnoses, the following diagnostic tests and procedures can be considered:

• Point-of-care ultrasound (POCUS) to evaluate for conditions such as pneumothorax, pleural effusion, and pericardial effusion, as recommended by 3.
• Chest radiograph (CXR) to evaluate for pneumonia and other conditions, although its added value may be minimal in patients with a normal thoracic ultrasound, as noted in 3.
• Electrocardiogram (ECG) to evaluate for cardiac causes of chest pain and palpitations.
• Complete blood count (CBC), basic metabolic panel (BMP), and troponin levels to evaluate for other potential causes of symptoms.

Consideration of Underlying Conditions

It is essential to consider the patient's underlying medical conditions, such as cardiovascular disease (CVD), as these can increase the risk of certain symptoms, as noted in 4. The study by 4 found that anxiety or depression, multiple other pain sites, and obesity were associated with reporting weekly chest pain and SOB in patients with CVD.

Further Evaluation and Management

Based on the initial assessment and diagnostic test results, further evaluation and management can be tailored to the patient's specific needs. The study by 5 highlights the importance of a thorough work-up to determine the etiology of SOB, and the study by 3 demonstrates the value of POCUS in narrowing down the differential diagnoses in patients with chest pain and SOB.