What is the next recommended workup in a Primary Care Physician (PCP) office for a patient with potential cardiac symptoms?

From the Guidelines

For a patient presenting with potential cardiac symptoms in a primary care setting, the next recommended workup should include a thorough history and physical examination, followed by an electrocardiogram (ECG) and basic laboratory tests, with a focus on serial cardiac troponin I or T levels at presentation and 3 to 6 hours after symptom onset, as recommended by the 2014 AHA/ACC guideline 1. The history should focus on characterizing chest pain or discomfort (location, radiation, quality, duration, aggravating/alleviating factors), associated symptoms (shortness of breath, diaphoresis, nausea), and cardiovascular risk factors.

• Laboratory tests should include cardiac biomarkers (troponin), complete blood count, comprehensive metabolic panel, lipid profile, and thyroid function tests.
• Additional appropriate tests include a resting 12-lead ECG and possibly a chest X-ray.
• If symptoms are concerning for acute coronary syndrome, the patient should be immediately referred to emergency care, as suggested by the 2014 AHA/ACC guideline for the management of patients with non-st-elevation acute coronary syndromes 1. For less urgent presentations, consider stress testing (exercise or pharmacologic) to evaluate for inducible ischemia, as recommended by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction 1. An echocardiogram may be warranted to assess cardiac structure and function. This systematic approach helps differentiate cardiac from non-cardiac causes while identifying patients requiring urgent intervention versus those who can be managed with outpatient follow-up, with risk stratification tools like HEART or TIMI scores guiding decision-making regarding the need for hospitalization versus outpatient management 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Recommended Workup in PCP Office

For a patient with potential cardiac symptoms, the next recommended workup in a Primary Care Physician (PCP) office may include:

• A 12-lead electrocardiogram (ECG) to assess cardiac function and identify potential abnormalities 2
• A complete blood count (CBC) to evaluate the risk of cardiovascular disease and metabolic diseases, as certain components of the CBC, such as white blood cell count and neutrophil-to-lymphocyte ratio, have been shown to be useful markers for predicting these conditions 3
• Liver blood tests, such as liver function tests, to rule out underlying liver disease that may be contributing to cardiac symptoms, as liver disease can sometimes present with cardiac manifestations 4
• A general health check, which may include a physical examination, medical history, and laboratory tests, to identify and prevent disease, and to assess the patient's overall health and risk factors for cardiovascular disease 5

Considerations for Cardiac Symptoms

When evaluating a patient with potential cardiac symptoms, it is essential to consider the following:

• The patient's medical history, including any previous cardiac conditions or risk factors
• The patient's symptoms, including the nature, severity, and duration of the symptoms
• The results of any diagnostic tests, such as the ECG and CBC
• The patient's overall health and risk factors for cardiovascular disease

Diagnostic Tests

The choice of diagnostic tests will depend on the patient's specific symptoms and medical history. Some common diagnostic tests used to evaluate cardiac symptoms include:

• ECG to assess cardiac function and identify potential abnormalities 2
• Echocardiogram to evaluate cardiac structure and function
• Stress test to evaluate cardiac function under stress
• Laboratory tests, such as troponin levels, to evaluate for cardiac injury or disease 6