What is the appropriate outpatient workup for a patient presenting with chest pain (pain around the ribcage) accompanied by nausea and vomiting?

From the Guidelines

The appropriate outpatient workup for a patient with chest pain accompanied by nausea and vomiting should begin with a thorough history and physical examination to assess risk factors for cardiac disease, followed by initial testing including an electrocardiogram (ECG), complete blood count, comprehensive metabolic panel, cardiac enzymes (troponin), and a chest X-ray, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The patient's symptoms of chest pain and nausea/vomiting should be taken seriously, as they may indicate a life-threatening condition such as acute coronary syndrome (ACS) or other cardiac issues. Key considerations in the workup include:

• Assessing the patient's risk factors for cardiac disease
• Evaluating for signs of cardiac ischemia or infarction
• Considering alternative causes of chest pain, such as gastrointestinal disorders
• Providing symptomatic treatment for nausea and vomiting, such as antiemetics like ondansetron 4mg every 8 hours as needed, while awaiting test results. Further testing, such as stress testing or coronary CT angiography, may be necessary depending on the patient's risk stratification and initial test results, as outlined in the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction 1. It is also important to note that patients with low cardiac risk but persistent symptoms may require evaluation for gastrointestinal causes, including upper endoscopy or abdominal ultrasound, as suggested by the ACC/AHA 2007 guidelines 1 and the European Heart Journal task force on the management of chest pain 1. Overall, a thorough and systematic approach to evaluating chest pain with nausea and vomiting is crucial to ensure timely diagnosis and treatment of potentially life-threatening conditions.

From the Research

Outpatient Workup for Chest Pain with Nausea/Vomiting

The outpatient workup for a patient presenting with chest pain (pain around the ribcage) accompanied by nausea and vomiting involves a comprehensive approach.

• A thorough history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary 2.
• The initial goal is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction 3.
• The physician should consider patient characteristics and risk factors to help determine initial risk 3.

Diagnostic Considerations

The following diagnostic considerations should be taken into account:

• Acute coronary syndrome and myocardial infarction 3
• Chest wall pain/costochondritis (localized pain reproducible by palpation) 3
• Gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth) 3
• Panic disorder/anxiety state 3
• Pneumonia (fever, egophony, and dullness to percussion) 3
• Heart failure 4
• Pulmonary embolism (consider using the Wells criteria) 3
• Acute pericarditis 3
• Acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities) 3

Diagnostic Testing

The following diagnostic tests may be considered:

• Twelve-lead electrocardiography to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions 3
• Chest radiograph to confirm the presence of heart failure 4
• Echocardiogram to confirm the diagnosis of heart failure 4
• Basic laboratory tests and plain radiography as initial diagnostic testing 2
• Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination 2

Management

Management of symptoms that are acute in onset or mild in severity may involve an empirical trial of antiemetics without extensive testing 5.

• In contrast, when symptoms are chronic or moderate-severe, testing for an underlying cause should be performed, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered in particular 5.