What is the initial workup and management for a patient presenting with chest pain?

Initial Workup and Management of Chest Pain

The initial workup for a patient presenting with chest pain should include a focused history of symptom characteristics, 12-lead ECG within 10 minutes of arrival, cardiac biomarkers, and risk stratification to identify life-threatening conditions requiring immediate intervention. 1

Initial Assessment

Focused History

• Nature of pain: Retrosternal chest discomfort that builds gradually over minutes, is precipitated by physical/emotional stress or occurs at rest
• Onset and duration: Sudden vs. gradual onset, intermittent vs. continuous
• Location and radiation: Central/retrosternal with radiation to left arm, neck, jaw
• Precipitating factors: Exertion, emotional stress, meals, position changes
• Relieving factors: Rest, nitroglycerin (not diagnostic but suggestive)
• Associated symptoms: Dyspnea, nausea/vomiting, diaphoresis, lightheadedness 1, 2

Red Flag Symptoms

• Symptoms that interrupt normal activity
• Accompanied by cold sweat, nausea, vomiting, fainting, anxiety/fear
• Severe, prolonged chest pain of acute onset 1

Physical Examination

Focus on:

• Vital signs (tachycardia, hypotension, hypertension)
• Cardiovascular exam (murmurs, gallops, rubs)
• Pulmonary exam (crackles, wheezes, decreased breath sounds)
• Signs of heart failure (JVD, peripheral edema)

Immediate Diagnostic Testing

1. 12-lead ECG within 10 minutes of arrival (Class I recommendation)

   • Look for ST-segment elevation/depression, T-wave inversions, Q waves
   • Compare with prior ECGs if available

2. Cardiac biomarkers

   • High-sensitivity cardiac troponin (hs-cTn) is preferred
   • Serial measurements (0h, 1-3h, 6h depending on assay)

3. Chest radiography

   • To evaluate for alternative causes (pneumothorax, pneumonia, aortic pathology)

Risk Stratification

Utilize validated risk scores to guide management:

• HEART score: History, ECG, Age, Risk factors, Troponin
• TIMI risk score: For patients with confirmed ACS
• GRACE score: For prognostication in ACS

Management Algorithm Based on Risk Assessment

High-Risk Features (Immediate Action Required)

• ST-elevation on ECG: Activate STEMI protocol for immediate reperfusion
• Hemodynamic instability: Stabilize and consider invasive management
• Elevated troponins with concerning ECG changes: Treat as NSTE-ACS
• Signs of aortic dissection: Urgent CT angiography and surgical consultation

Intermediate Risk

• Serial ECGs and cardiac biomarkers
• Consider early stress testing or coronary CT angiography
• Initiate anti-ischemic therapy:
  • Aspirin 325mg chewable
  • Nitroglycerin (if SBP >90 mmHg)
  • Beta-blockers (e.g., metoprolol) if no contraindications 3

Low Risk

• Consider early discharge with outpatient follow-up if:
  • Normal serial ECGs
  • Negative serial troponins
  • No concerning features on history/examination
  • HEART score <3

Special Considerations

Age-Related Differences

• Younger patients (<40 years): Lower yield from routine stress testing (0-1.1% positive results) 4
• Elderly patients (>65 years): Higher prevalence of atypical presentations and non-cardiac causes

Gender Differences

• Women may present with more atypical symptoms (fatigue, dyspnea, epigastric discomfort)
• Higher rate of non-obstructive coronary disease in women

Common Pitfalls to Avoid

1. Relying solely on pain characteristics: Chest pain intensity correlates poorly with severity of myocardial injury 5

2. Premature diagnostic closure: Consider multiple potential causes including:

   • Cardiac: ACS, pericarditis, myocarditis
   • Pulmonary: PE, pneumothorax, pneumonia
   • Gastrointestinal: GERD, esophageal spasm
   • Musculoskeletal: costochondritis

3. Delayed ECG acquisition: ECG should be obtained within 10 minutes of arrival

4. Overreliance on a single troponin value: Serial measurements improve sensitivity

5. Dismissing chest pain in young patients: Though less common, ACS can occur in young adults

Pre-Hospital Management

For patients with suspected cardiac chest pain in pre-hospital setting:

• Administer aspirin 325mg (chewable)
• Consider nitroglycerin if SBP >90 mmHg
• Provide supplemental oxygen only if hypoxemic (SpO2 <90%)
• Expedite transport to appropriate facility 1

By following this systematic approach to chest pain evaluation, clinicians can rapidly identify life-threatening conditions while appropriately risk-stratifying patients for efficient and effective management.