What are the next steps for a patient presenting with left-sided sharp chest pain?

Management of Left-Sided Sharp Chest Pain

For a patient presenting with left-sided sharp chest pain, an immediate focused history, physical examination, and 12-lead ECG should be performed to rule out life-threatening conditions, with urgent referral to the emergency department if concerning features are present. 1

Initial Assessment

History - Key Features to Evaluate

• Nature of pain: Sharp chest pain is less likely to be ischemic in origin compared to pressure, heaviness, or squeezing sensations 1
• Timing and onset:
  • Sudden onset vs. gradual buildup
  • Duration (fleeting pain of few seconds is unlikely to be cardiac)
  • Relationship to respiration or position
• Location and radiation:
  • Precisely localized pain is less likely to be cardiac
  • Pain radiating to jaw, neck, shoulders, or arms increases cardiac suspicion
• Aggravating/relieving factors:
  • Pain worsened by inspiration or lying supine suggests pericarditis
  • Pain worsened by movement or palpation suggests musculoskeletal cause
  • Positional pain is usually non-ischemic 1

Physical Examination

• Vital signs (tachycardia, hypotension, tachypnea may indicate serious pathology)
• Cardiovascular examination (murmurs, rubs, abnormal heart sounds)
• Chest wall tenderness (suggests musculoskeletal origin)
• Respiratory examination (decreased breath sounds, crackles)
• Assessment for peripheral pulse deficits (aortic dissection) 1

Immediate Actions

1. Obtain 12-lead ECG within 10 minutes of presentation to evaluate for STEMI or other acute cardiac abnormalities 1

2. Risk stratification based on:

   • Age (higher risk in older patients)
   • Cardiovascular risk factors
   • Associated symptoms (diaphoresis, nausea, dyspnea)
   • Hemodynamic stability

3. Decision point for setting of care:

   • If office/outpatient setting and ECG unavailable, refer to ED 1
   • If concerning features present, arrange urgent transport to ED, preferably by EMS 1

Differential Diagnosis for Left-Sided Sharp Chest Pain

Cardiac Causes

• Acute coronary syndrome (though less likely with sharp pain)
• Pericarditis (sharp pain that worsens with inspiration and lying supine)
• Stress cardiomyopathy

Pulmonary Causes

• Pulmonary embolism (often with dyspnea, tachycardia)
• Pneumothorax (sudden onset, decreased breath sounds)
• Pleuritis/pneumonia (pain with respiration)

Musculoskeletal Causes

• Costochondritis (reproducible tenderness at costochondral junctions)
• Chest wall syndrome (most common cause in primary care settings) 1

Other Causes

• Aortic dissection (sudden, severe "ripping" pain)
• Esophageal disorders (spasm, reflux, rupture)
• Herpes zoster (may precede rash)

Management Algorithm

1. If any red flags present, immediate ED referral:

   • Severe pain described as "worst ever"
   • Abnormal vital signs (hypotension, tachycardia)
   • Abnormal ECG findings
   • Associated symptoms like syncope, diaphoresis, or dyspnea
   • Age ≥75 years with shortness of breath, syncope, or acute delirium 1

2. If in outpatient setting with stable patient:

   • Obtain ECG if available
   • If ECG unavailable or shows abnormalities, refer to ED 1
   • Do not delay transfer to ED for cardiac troponin testing 1

3. If high suspicion for ACS despite normal initial ECG:

   • Administer aspirin (162-325 mg, non-enteric coated for faster absorption) 1
   • Consider nitroglycerin if no contraindications 1
   • Arrange urgent transport to ED

Pitfalls to Avoid

1. Dismissing chest pain in women - Women are at risk for underdiagnosis; cardiac causes should always be considered, even with atypical presentations 1

2. Relying solely on pain characteristics - Sharp pain can still represent serious pathology; correlation between pain intensity and disease severity is poor 1

3. Delaying ECG - ECG should be obtained within 10 minutes of presentation for all patients with acute chest pain 1

4. Office-based cardiac troponin testing - Delayed transfer to ED for troponin testing should be avoided; immediate referral is preferred 1

5. Assuming musculoskeletal origin without proper evaluation - Even when chest wall tenderness is present, cardiac causes must be excluded first

Remember that while left-sided sharp chest pain is often non-cardiac in origin, potentially life-threatening conditions must be ruled out through systematic evaluation before attributing symptoms to benign causes.