What is the initial workup and management for a patient presenting to the emergency department (ED) with chest pain?

Initial Workup and Management of Chest Pain in the Emergency Department

For patients presenting to the emergency department with chest pain, an ECG should be obtained and reviewed within 10 minutes of arrival, followed by cardiac troponin measurement and focused history and physical examination to rapidly identify life-threatening causes. 1

Initial Assessment (First 10 Minutes)

1. Immediate Diagnostic Steps

• ECG: Obtain and review within 10 minutes of arrival 2, 1

  • Look for ST-segment elevation, depression, T-wave inversions, or new arrhythmias
  • If initial ECG is nondiagnostic but clinical suspicion remains high, obtain serial ECGs 2
  • Consider supplemental leads V7-V9 to rule out posterior MI if initial ECG is nondiagnostic 2, 1

• Vital Signs: Assess for hemodynamic instability, which may indicate a high-risk condition

• Cardiac Biomarkers: Measure cardiac troponin (cTn) as soon as possible after presentation 2, 1

  • Preferably use high-sensitivity troponin (hs-cTn) assays if available
  • For nondiagnostic initial troponin, repeat at 1-2 hours for hs-cTn assays or 3-6 hours for conventional cTn assays 1

2. Focused History

Obtain a focused history assessing:

• Characteristics of chest pain (nature, onset, duration, location, radiation) 2
• Precipitating and relieving factors
• Associated symptoms
• Cardiovascular risk factors

Key chest pain characteristics suggesting cardiac origin:

• Retrosternal discomfort described as pressure, heaviness, or squeezing
• Gradual onset building over minutes
• Radiation to left arm, jaw, or back
• Provoked by exertion or emotional stress
• Associated with dyspnea, diaphoresis, nausea, or lightheadedness

3. Physical Examination

Perform a focused cardiovascular examination to identify:

• Signs of heart failure (rales, S3 gallop, elevated JVP)
• New murmurs suggesting valvular pathology or mechanical complications
• Signs of alternative diagnoses (friction rub, unequal pulses, etc.)

Risk Stratification and Management

High-Risk Features (Immediate Action Required)

• ECG showing STEMI or new LBBB: Follow STEMI guidelines 2, 1
• Hemodynamic instability
• Ongoing severe chest pain unresponsive to nitrates
• Signs of heart failure
• Syncope/near-syncope

Management Based on ECG Findings

If STEMI or New LBBB:

• Activate STEMI protocol
• Immediate reperfusion strategy (thrombolysis or primary PCI) 2
• Aspirin 162-325 mg (chewed) 1
• Pain control with morphine titrated to effect 2
• Consider nitroglycerin for ongoing pain (0.4 mg SL, may repeat every 5 minutes for up to 3 doses) 3
  • Caution: Avoid in patients with hypotension, recent PDE-5 inhibitor use, or right ventricular infarction 3

If ST Depression or T-wave Inversions (NSTE-ACS):

• Aspirin 162-325 mg
• Consider antithrombotic therapy 2
• Serial cardiac biomarkers
• Consider early invasive strategy for high-risk features

If Normal or Nondiagnostic ECG:

• Serial ECGs (especially with ongoing symptoms) 2
• Serial cardiac biomarkers
• Consider additional diagnostic testing based on clinical suspicion

Additional Diagnostic Evaluation

Chest Radiography

• Useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms 2
• May reveal widened mediastinum (aortic dissection), pneumothorax, pneumonia, or pulmonary edema 2

Additional Testing Based on Clinical Suspicion

• Suspected Pulmonary Embolism: D-dimer (if low pretest probability) or CT pulmonary angiography 1
• Suspected Aortic Dissection: CT angiography of chest, abdomen, and pelvis 1
• Suspected Pericarditis/Myocarditis: Echocardiography, consider cardiac MRI 1
• Intermediate Risk for ACS with Negative Initial Workup: Consider stress testing, coronary CT angiography, or observation in chest pain unit 2, 4

Common Pitfalls to Avoid

1. Delayed ECG acquisition - Can delay diagnosis and treatment of STEMI 1
2. Relying solely on initial normal ECG - Up to 6% of patients with evolving ACS are discharged with a normal ECG 2
3. Missing posterior MI - Consider supplemental leads V7-V9 when clinical suspicion is high but standard ECG is nondiagnostic 2, 1
4. Premature discharge with mildly elevated troponin - Even small elevations in high-sensitivity troponin carry prognostic significance 5
5. Delaying transfer for additional testing in office settings - This can worsen outcomes 1

Special Considerations

• Elderly Patients: May present with atypical symptoms such as shortness of breath, syncope, acute delirium, or unexplained falls rather than classic chest pain 2
• Women: More likely to present with atypical symptoms including fatigue, dyspnea, or epigastric discomfort
• Diabetics: May have diminished pain perception due to neuropathy
• Cocaine/Methamphetamine Users: Consider drug-induced coronary vasospasm 1

The European Heart Journal task force on chest pain management emphasizes that patients with ongoing chest pain should be admitted to specialized coronary care or intensive care units without delay, as this approach has been associated with a 53% reduction in mortality 2.