From the Guidelines
A cardiac workup for chest pain should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG) and cardiac biomarkers like troponin, with an ECG acquired and reviewed for ST-segment–elevation myocardial infarction (STEMI) within 10 minutes of arrival 1. When evaluating a patient with chest pain, it is essential to consider the potential causes, ranging from minor chest wall strains to life-threatening conditions like acute coronary syndrome, pulmonary embolism, or aortic dissection.
- Initial testing should include a 12-lead ECG within 10 minutes of presentation and serial troponin measurements at 0,3, and 6 hours, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
- Additional tests may include a complete blood count, basic metabolic panel, chest X-ray, and echocardiogram.
- For patients with intermediate risk, stress testing is appropriate, with options including exercise treadmill testing, stress echocardiography, or nuclear perfusion imaging.
- High-risk patients may require coronary CT angiography or invasive coronary angiography. During evaluation, consider administering aspirin (325 mg) as it improves survival in patients with myocardial infarction, according to the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
- Sublingual nitroglycerin (0.4 mg every 5 minutes for up to 3 doses) can be administered for active pain.
- Oxygen should only be administered if saturation is below 94%, as the AHA does not recommend administration of oxygen in health care settings for people with acute coronary syndromes who are not hypoxic 1. Risk stratification tools like HEART, TIMI, or GRACE scores help determine the appropriate level of care and follow-up, ensuring proper identification of life-threatening conditions while addressing other potential causes of chest pain.
From the Research
Chest Pain Cardiac Workup
- The evaluation of patients with suspected acute coronary syndrome (ACS) begins with an electrocardiogram (ECG) obtained within 10 minutes of presentation 2.
- If ST-segment elevation is present, ST-segment elevation MI (STEMI) is diagnosed, and rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality 3.
- If STEMI is not present, troponin levels should be measured using one of several recommended protocols, and troponin levels greater than 99th percentile of the upper reference limit are consistent with ACS 2.
- For patients with non-ST-segment elevation ACS (NSTE-ACS), high-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI, and prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death 3.
Diagnostic Evaluation
- Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves 4.
- Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation ACS 4.
- Risk stratification should be calculated using Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score to determine the need for further evaluation to exclude coronary artery disease (CAD) 2.
Management
- Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization, as well as initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy 4.
- Aspirin should be administered as soon as possible, if not contraindicated, to patients with suspected ACS 5.
- Clopidogrel has been shown to be associated with significantly better outcomes in patients with acute coronary syndrome when added to regular aspirin therapy 6.