What is the treatment for a patient with fleeting chest pain?

Management of Fleeting Chest Pain

Fleeting chest pain (lasting only a few seconds) is unlikely to be related to ischemic heart disease and generally does not require emergency evaluation. 1

Initial Assessment

When a patient presents with fleeting chest pain:

1. Determine duration and characteristics:

   • Fleeting pain (lasting seconds) is rarely cardiac in origin 1
   • Pain that can be localized to a very limited area is unlikely to be ischemic 1
   • Pain that increases with inspiration, position changes, or palpation suggests non-cardiac origin 1

2. Assess for concerning features:

   • If pain is accompanied by dyspnea, diaphoresis, nausea, or radiation to arms/jaw, more thorough evaluation is needed 1
   • Patients with known coronary artery disease require more careful assessment even with brief pain 1

Management Algorithm

For Truly Fleeting Pain (seconds duration):

1. Low-risk features (all present):

   • Pain lasting only seconds
   • No associated symptoms
   • Normal vital signs
   • No history of coronary disease
   • Pain reproducible with palpation or movement

   Management: Reassurance and follow-up as needed. Consider non-cardiac causes such as musculoskeletal pain 1

2. Intermediate-risk features (any present):

   • History of coronary disease
   • Multiple cardiovascular risk factors
   • Age >40 years
   • Recurrent episodes

   Management: Consider ECG and focused cardiac assessment. If normal, outpatient follow-up is appropriate 1

3. High-risk features (any present):

   • Multiple episodes in short timeframe
   • Associated symptoms (dyspnea, diaphoresis)
   • Abnormal vital signs
   • Known severe coronary disease

   Management: Perform ECG, consider cardiac biomarkers, and more comprehensive evaluation 1

Important Distinctions

• Fleeting vs. prolonged pain: Severe prolonged chest pain of acute onset requires immediate action and hospital evaluation 1
• Musculoskeletal causes: Pain reproducible by palpation is more likely musculoskeletal than ischemic 2
• Panic attacks: Consider screening with a two-item questionnaire if anxiety-related symptoms are present 2

Common Pitfalls

1. Dismissing all brief pain: While fleeting pain is unlikely to be cardiac, the pattern of recurrence and associated symptoms matter
2. Over-investigation: Not every episode of fleeting chest pain requires extensive cardiac workup
3. Failure to follow up: Even if initial assessment is reassuring, establish a plan for recurrent symptoms

When to Refer for Emergency Evaluation

Despite the typically benign nature of fleeting chest pain, immediate evaluation is warranted if:

• Pain becomes recurrent or prolonged (>5 minutes) 1
• New ECG changes are present
• Patient develops hemodynamic instability 1
• Patient has known severe coronary disease with changing symptom pattern

Follow-up Recommendations

For patients with isolated fleeting chest pain and no concerning features:

• Education about warning signs requiring urgent evaluation
• Consider outpatient evaluation if episodes recur or change in character
• Address modifiable cardiovascular risk factors if present

Remember that while fleeting chest pain is rarely cardiac in origin, the overall clinical picture should guide management decisions, with particular attention to the patient's risk profile and associated symptoms.