What is the workup for chest pain and shortness of breath (SOB)?

From the Guidelines

The workup for chest pain and shortness of breath (SOB) should begin with a thorough history and physical examination, followed by targeted diagnostic tests, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The initial evaluation should include vital signs, oxygen saturation, ECG, chest X-ray, and basic laboratory tests including complete blood count, basic metabolic panel, cardiac enzymes (troponin), BNP, and D-dimer.

• For suspected cardiac causes, serial troponins should be obtained 3-6 hours apart, and additional cardiac testing may include echocardiogram, stress testing, or cardiac CT angiography depending on risk stratification, as suggested by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.
• If pulmonary embolism is suspected based on risk factors or elevated D-dimer, CT pulmonary angiography is recommended.
• For suspected pneumonia or other pulmonary conditions, sputum cultures and pulmonary function tests may be appropriate.
• In cases of suspected aortic dissection, CT angiography of the chest with contrast is the preferred imaging modality. The urgency and extent of workup should be guided by the patient's presentation, with immediate attention to potentially life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection, tension pneumothorax, and severe pneumonia, as emphasized by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. This systematic approach helps identify the underlying cause of chest pain and shortness of breath, allowing for appropriate treatment to be initiated promptly. Key considerations in the workup include:
• Activating EMS for individuals experiencing chest pain or other symptoms that might indicate a myocardial infarction, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
• Administering aspirin in the dose of 162 to 324 mg to improve survival in patients with myocardial infarction, as suggested by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
• Assessing LV function with echocardiography or another modality in patients with documented ischemia, as recommended by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.

From the Research

Workup for Chest Pain and Shortness of Breath (SOB)

The workup for chest pain and shortness of breath (SOB) involves a combination of patient history-taking, physical examination, and clinical investigations. The following steps are typically taken:

• Patient history-taking to identify the cause of chest pain and SOB, including the use of structured assessment tools and evidence-based guidelines 2
• Physical examination to assess the patient's overall condition and identify any potential causes of chest pain and SOB
• Clinical investigations, such as electrocardiograms (ECGs), cardiac injury markers, and imaging studies, to diagnose or rule out life-threatening conditions such as acute coronary syndrome (ACS) 3

Diagnostic Tools and Protocols

Several diagnostic tools and protocols are available to help identify low-risk patients with chest pain, including:

• The thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS 4
• The Asia-Pacific Evaluation of Chest Pain Trial (ASPECT), Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT), North American Chest Pain Rule (NACPR), and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score, which have been developed exclusively for use in the undifferentiated chest pain population 4
• The "triple rule-out" computed tomography angiography, which can be used to detect coronary artery disease, acute aortic syndrome, and pulmonary emboli in patients with low to intermediate increased risk for ACS 5

ECG Prioritization Rule

An ECG prioritization rule has been developed to identify patients who require an immediate 12-lead ECG in the emergency department to identify ST-elevation myocardial infarction (STEMI), including those without chest pain 6. The rule is based on age and presenting symptoms, including:

• Age ≥30 years with chest pain
• Age ≥50 years with shortness of breath, altered mental status, upper extremity pain, syncope, or generalized weakness
• Age ≥80 years with abdominal pain or nausea/vomiting This rule has been shown to have a high sensitivity and negative predictive value for STEMI 6