What are the guidelines for evaluating and managing chest pain (thoracic pain)?

From the Guidelines

Chest pain evaluation should follow a systematic approach to identify life-threatening causes while avoiding unnecessary testing, as recommended by the most recent guidelines 1. The initial assessment should include a detailed history focusing on pain characteristics (onset, quality, radiation, aggravating/alleviating factors), vital signs, physical examination, ECG, and cardiac biomarkers like troponin. Some key points to consider in the evaluation of chest pain include:

• High-risk features warranting immediate attention, such as crushing/pressure-like pain radiating to the arm/jaw, associated shortness of breath, diaphoresis, nausea, or pain worsening with exertion.
• The use of high-sensitivity troponins as the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
• The importance of early care for acute symptoms, with patients seeking medical care immediately by calling 9-1-1, as emphasized in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
• The need to share decision-making with clinically stable patients, providing information about risk of adverse events, radiation exposure, costs, and alternative options, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
• The use of clinical decision pathways for chest pain in the emergency department and outpatient settings, as suggested by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. For suspected acute coronary syndrome, administer aspirin 325mg immediately, consider nitroglycerin 0.4mg sublingually for ongoing pain (avoid if systolic BP <90mmHg or recent phosphodiesterase inhibitor use), and obtain serial troponins at 0 and 3 hours, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. Patients with STEMI need immediate reperfusion therapy. For stable patients with intermediate risk, consider stress testing or coronary CT angiography, as suggested by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. Non-cardiac causes like pulmonary embolism, aortic dissection, pneumothorax, or esophageal disorders should be ruled out based on clinical presentation. This approach balances prompt identification of emergent conditions while preventing overdiagnosis, as chest pain has numerous potential etiologies ranging from life-threatening cardiac conditions to benign musculoskeletal causes, as noted in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1 and the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

From the Research

Evaluation of Chest Pain

• The evaluation of chest pain involves determining whether the pain is cardiac in origin or not 2
• If the pain is suspected to be cardiac, the next step is to determine if it is secondary to an acute coronary syndrome (ACS) that requires immediate referral to an emergency room 2
• The development and evolution of the ED-based observation unit has helped to safely assess and diagnose those most at risk for an adverse cardiac event 3

Management of Chest Pain

• The management of chest pain involves a systematic approach to determine the likelihood of significant coronary artery disease (CAD) based on the patient's history, risk factors, and electrocardiogram 2
• Several provocative testing modalities are available to help assess for coronary artery disease 3
• Clinical decision aids, such as the TIMI risk score, GRACE scores, ASPECT, ADAPT, NACPR, and HEART score, have been developed to risk-stratify patients and better direct the workup and care given 4

Quality of Care

• The quality of care for patients presenting with non-traumatic acute chest pain (NTACP) in the emergency room can be evaluated using quality indicators of a universal chain of survival 5
• These indicators include early symptom recognition and call for help, emergency medical service (EMS) evaluation and treatment, ED evaluation and treatment, and reperfusion therapy 5
• Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin is heterogeneous across different regions and can be improved with specific practical guidelines 6

Diagnostic Testing

• Diagnostic testing, such as ECG, chest x-ray, echocardiography, and cardiac enzyme evaluation, is essential in the acute phase of care for patients presenting with NTACP 5
• The use of these tests can help identify patients with ACS and guide further management 5