Initial Assessment and Management of Chest Pain
The initial assessment of a patient with chest pain must include an ECG within 10 minutes of arrival, cardiac troponin measurement, and rapid triage to identify life-threatening causes requiring immediate intervention. 1
Immediate Assessment (First 10 Minutes)
History
- Obtain focused chest pain characteristics:
- Nature: Retrosternal discomfort, pressure, heaviness, tightness (suggestive of ACS)
- Onset and duration: Gradual build over minutes (typical of angina) vs. sudden ripping pain (aortic dissection)
- Location and radiation: Central chest with radiation to arm, jaw, or back
- Precipitating/relieving factors: Exercise, stress, rest, nitroglycerin response
- Associated symptoms: Dyspnea, diaphoresis, nausea, lightheadedness
Physical Examination
- Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation, temperature
- Cardiovascular: Heart sounds, murmurs, S3 gallop, signs of heart failure
- Respiratory: Breath sounds, crackles, pleural rub
- Vascular: Pulse deficits, asymmetric blood pressure (aortic dissection)
- Chest wall: Tenderness, reproducible pain
Immediate Diagnostic Testing
- 12-lead ECG within 10 minutes of arrival (Class I, Level C-LD) 1
- Cardiac troponin measurement as soon as possible if ACS suspected (Class I, Level C-LD) 1
Risk Stratification and Management Algorithm
High-Risk Features (Immediate Action Required)
- ST-segment elevation or new LBBB: Activate STEMI protocol, immediate reperfusion
- Hemodynamic instability: Hypotension, tachycardia, respiratory distress
- Signs of heart failure: Crackles, S3 gallop, elevated JVP
- High-risk ECG changes: ST depression, T-wave inversions
- Positive cardiac troponin
Management Based on Suspected Etiology
1. Suspected Acute Coronary Syndrome
- Immediate interventions:
- Aspirin 325 mg chewed (unless contraindicated)
- Nitroglycerin sublingual (if BP >90 mmHg)
- Supplemental oxygen if hypoxemic (O2 sat <94%)
- Consider IV beta-blocker (e.g., metoprolol) if tachycardic or hypertensive without contraindications 2
- Pain control with morphine if needed
- Disposition: Transfer to cardiac care unit or catheterization laboratory
2. Suspected Aortic Dissection
- Immediate interventions:
- Control blood pressure (IV beta-blockers first, then vasodilators)
- Avoid anticoagulation/antiplatelet therapy
- Urgent CT angiography or transesophageal echocardiography
- Disposition: Immediate surgical consultation, ICU admission
3. Suspected Pulmonary Embolism
- Immediate interventions:
- Supplemental oxygen if hypoxemic
- Consider empiric anticoagulation if high suspicion and no contraindications
- CT pulmonary angiography or V/Q scan
- Disposition: Admission for confirmed PE or high clinical suspicion
4. Other Potentially Life-Threatening Causes
- Tension pneumothorax: Immediate needle decompression
- Esophageal rupture: Surgical consultation, broad-spectrum antibiotics
- Pericarditis/myocarditis: ECG, echocardiography, anti-inflammatory therapy
Setting Considerations
Office/Outpatient Setting
- If ECG unavailable, refer immediately to ED (Class I, Level B-NR) 1
- For suspected ACS or other life-threatening causes, arrange urgent transport to ED by EMS (Class I, Level C-LD) 1
- Avoid delayed transfer for troponin testing (Class III: Harm, Level C-LD) 1
Emergency Department Setting
- Implement standardized chest pain protocols
- Consider chest pain unit observation for intermediate-risk patients
- Serial ECGs and troponin measurements (0,3,6 hours)
- Consider early functional testing or coronary CT angiography for low-intermediate risk
Common Pitfalls and Caveats
Atypical presentations: Women, elderly, and diabetic patients often present with atypical symptoms (fatigue, dyspnea, epigastric discomfort) rather than classic chest pain.
Normal ECG does not rule out ACS: Up to 50% of patients with AMI may have a non-diagnostic initial ECG 3.
Early troponin can be negative: Serial measurements are essential as troponin may take 3-6 hours to become positive after symptom onset.
Overreliance on single tests: No single test can rule out all serious causes of chest pain; integrate clinical assessment with appropriate testing.
Premature discharge: Patients with initially negative workups still require appropriate risk stratification before discharge.
By following this systematic approach to chest pain evaluation, clinicians can rapidly identify life-threatening conditions requiring immediate intervention while appropriately triaging lower-risk patients to appropriate levels of care.