What are the initial assessments and management for a patient presenting with chest pain?

From the Guidelines

The initial assessment of a patient with chest pain should begin with a rapid evaluation of vital signs, obtaining a focused history, and performing a targeted physical examination while simultaneously initiating diagnostic testing, as recommended by the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1. The assessment should include:

• Evaluating the patient's airway, breathing, and circulation
• Obtaining vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature
• Immediately obtaining a 12-lead ECG within 10 minutes of arrival to evaluate for ST-elevation myocardial infarction (STEMI) or other concerning findings, as emphasized in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1
• Laboratory tests, including cardiac biomarkers (troponin), complete blood count, basic metabolic panel, and coagulation studies
• Administering supplemental oxygen if oxygen saturation is below 94%
• For suspected acute coronary syndrome, giving aspirin 325mg chewed immediately unless contraindicated, and considering nitroglycerin 0.4mg sublingual every 5 minutes for up to 3 doses if systolic blood pressure is above 90mmHg, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1
• If STEMI is identified, activating the cardiac catheterization laboratory for primary percutaneous coronary intervention, with a door-to-balloon time goal of less than 90 minutes, as emphasized in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1
• For patients with intermediate to high-risk features, additional medications may include antiplatelet agents (P2Y12 inhibitors like clopidogrel 300-600mg loading dose), anticoagulants (unfractionated heparin, enoxaparin, or fondaparinux), and beta-blockers if hemodynamically stable, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1

Key considerations in the assessment and management of chest pain include:

• Rapid identification of life-threatening causes of chest pain, such as acute coronary syndrome, pulmonary embolism, and aortic dissection
• Providing symptomatic relief and initiating treatment for the most common serious etiology, acute coronary syndrome
• Using evidence-based clinical decision pathways to guide assessment and management, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1
• Considering the patient's individual risk factors and clinical presentation when making management decisions, as emphasized in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Assessments for Chest Pain

• The first step in assessing a patient with chest pain is to obtain a complete and thorough history, including family history and risk factors 2.
• A physical examination should be performed, which may include important tests such as a chest X-ray, 12-lead electrocardiograph, and cardiac isoenzymes 2.
• Electrocardiography should be performed immediately (within 10 minutes of presentation) to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 3.
• High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI 3.

Management of Chest Pain

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 4, 5.
• Addition of a second antiplatelet (ie, dual antiplatelet therapy) and parenteral anticoagulation are also recommended for most patients 4.
• Nitroglycerin and beta blockers should be administered to relieve angina, if not contraindicated 4, 5.
• For patients with STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality 3, 5.
• If PCI within 120 minutes is not possible, fibrinolytic therapy should be administered for patients younger than 75 years without contraindications 3.

Diagnostic Considerations

• Echocardiography can be utilized to diagnose acute coronary syndrome, aortic dissection, and pulmonary embolism by detecting wall motion abnormalities, intimal flap, and pulmonary hypertension 6.
• A perceptive and observant nurse with astute assessment skills will set the tone for optimal patient treatment leading to a more positive outcome for the patient 2.
• Life-threatening diseases such as acute coronary syndrome, aortic dissection, and pulmonary embolism should be considered first, and if these lethal diseases are ruled out, every possibility including diseases other than cardiovascular disease must be considered 6.