What is the current recommended management for chest pain in the ambulatory setting?

Management of Chest Pain in the Ambulatory Setting

In patients with acute chest pain in the ambulatory setting, an ECG should be acquired and reviewed for STEMI within 10 minutes of arrival, and patients with suspected ACS or other life-threatening causes should be transported urgently to the emergency department (ED), ideally by EMS. 1

Initial Evaluation Algorithm

1. Immediate ECG (within 10 minutes)

   • Must be performed for all patients with chest pain regardless of setting 1
   • If ECG cannot be obtained in the office setting, immediate transfer to ED by EMS is required 1

2. Risk Assessment

   • High-risk features (requiring immediate EMS transport):
     • New ST-elevation, ST depression, or new left bundle branch block on ECG
     • Hemodynamic instability (hypotension, tachycardia)
     • Ongoing severe pain unresponsive to nitrates
     • Signs of heart failure
     • Syncope or near-syncope

3. Transport Decision

   • For suspected ACS or other life-threatening conditions: Immediate EMS transport to ED 1
   • For stable angina or non-cardiac chest pain: Outpatient management may be appropriate 1

Critical Pitfalls to Avoid

• NEVER delay transfer to obtain cardiac troponin (cTn) in the office setting - this is explicitly identified as harmful (Class III: Harm) 1
• NEVER send patients with suspected ACS by private vehicle - approximately 1 in 300 patients transported by private vehicle experience cardiac arrest en route 1
• NEVER rely on a single normal ECG to exclude ACS - serial ECGs are needed if symptoms persist 1

Specific Management Steps

For Suspected ACS

1. Administer aspirin 162-325 mg (chewed) if not contraindicated 1
2. Consider sublingual nitroglycerin for pain relief if systolic BP >90 mmHg 2
3. Arrange immediate EMS transport to ED 1
4. Inform EMS of suspected ACS to facilitate appropriate pre-hospital care 1

For Suspected Aortic Dissection

1. DO NOT administer aspirin or other antithrombotics 1
2. Arrange immediate EMS transport to a center with 24/7 aortic imaging and cardiac surgery capabilities 1

For Suspected Pulmonary Embolism

1. Use clinical prediction scores to determine likelihood 1
2. Arrange transfer to ED or chest pain unit for stable patients 1
3. For unstable patients, arrange transfer to centers equipped for thrombectomy 1

Special Populations

Pediatric Patients

• Most pediatric chest pain is non-cardiac in origin 3
• ECG should still be performed to rule out rare cardiac causes 3
• Consider chest radiography if abnormal pulmonary exam or persistent symptoms 3

Patients on Dialysis

• Patients experiencing chest pain during dialysis should be transferred by EMS to an acute care setting 1

Patients with Cocaine/Methamphetamine Use

• Consider stimulant use as a potential cause of chest pain 1
• These patients still require ECG evaluation and may need ED referral

Evidence Quality and Limitations

The recommendations are primarily based on Class 1 evidence (strong recommendation) from the 2021 AHA/ACC guidelines 1, though much of this evidence is Level C (limited data), reflecting the challenges of conducting randomized trials in emergency cardiac care. The guidelines emphasize the importance of rapid ECG and prompt transfer decisions over diagnostic testing in the ambulatory setting.

The most critical point emphasized across all guidelines is that patients with suspected ACS should not have their transfer to an ED delayed for additional testing in the ambulatory setting, as this can significantly worsen outcomes 1.