What is the approach for a patient presenting with chest pain?

Approach to Chest Pain Evaluation and Management

Patients with chest pain should be rapidly assessed for life-threatening causes, with immediate hospital care needed for severe, prolonged chest pain of acute onset regardless of cause. 1

Initial Assessment

History Taking

• Characterize pain using OPQRST method 2:

  • Onset: Sudden vs. gradual
  • Provocation/Palliation: What worsens or relieves it
  • Quality: Pressure, tightness, burning, stabbing
  • Radiation: To arms, neck, jaw, back
  • Severity: On scale of 1-10
  • Time: Duration and pattern

• High-risk features in history 1, 2:

  • Interruption of normal activity
  • Accompanied by cold sweat, nausea, vomiting, dyspnea
  • Central chest pain with radiation to arms, neck, jaw
  • Similar to previous cardiac events
  • Age >65 years, known cardiovascular disease

• Low-risk features in history 1, 2:

  • Pain that varies with respiration or position
  • Well-localized to chest wall with tenderness
  • Pain affected by movement, twisting, bending
  • Brief, stabbing pain lasting seconds

Physical Examination

• Perform focused cardiovascular examination to identify 1, 2:
  • Vital signs: Tachycardia, hypotension, tachypnea
  • Heart sounds: S3, murmurs (especially new MR murmur)
  • Lung examination: Crackles, unilateral decreased breath sounds
  • Vascular examination: Pulse differentials (aortic dissection)
  • Chest wall tenderness (musculoskeletal causes)

Immediate Actions for Suspected Acute Coronary Syndrome

1. Call emergency services (9-1-1) for severe chest pain 1
2. Administer aspirin 250-500mg (chewed) immediately 1, 2, 3, 4
   • Early aspirin administration improves survival compared to delayed administration 4
3. Consider sublingual nitroglycerin if no bradycardia or hypotension 1, 5
   • Use with caution in volume-depleted patients 5
   • Avoid in patients taking PDE-5 inhibitors 5
4. For severe pain, consider opiates for pain relief 1
5. Obtain 12-lead ECG within 10 minutes of presentation 2, 6
   • Consider supplemental leads V7-V9 if posterior MI suspected 2
6. Obtain serial cardiac troponin measurements 1, 2, 6
7. Obtain chest radiography to evaluate for other causes 2

Risk Stratification

High-Risk Features (Require Immediate Action) 2, 6:

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

Intermediate-Risk Features 2:

• Known coronary artery disease
• Multiple cardiovascular risk factors
• Age >65 years
• ECG changes not meeting STEMI criteria
• Mildly elevated troponin

Low-Risk Features 2:

• Young age
• Atypical symptoms
• Normal ECG
• Normal troponin

Special Considerations

Women with Chest Pain 1, 2:

• At risk for underdiagnosis
• More likely to present with accompanying symptoms:
  • Shortness of breath
  • Nausea/vomiting
  • Fatigue
  • Pain in throat or abdomen

Elderly Patients (>75 years) 1, 2:

• Consider ACS when presenting with:
  • Shortness of breath
  • Syncope
  • Acute delirium
  • Unexplained falls

Differential Diagnosis

Clinical Syndrome	Key Findings
Acute Coronary Syndrome	Diaphoresis, tachypnea, tachycardia; exam may be normal in uncomplicated cases [1]
Aortic Dissection	Severe pain with abrupt onset, pulse differential, widened mediastinum on CXR [1,2]
Pulmonary Embolism	Tachycardia + dyspnea (>90%), pain with inspiration [1,2]
Pneumothorax	Unilateral decreased/absent breath sounds, dyspnea [1,2]
Pericarditis	Fever, pleuritic pain worse in supine position, friction rub [1,2]
Esophageal Rupture	Emesis, subcutaneous emphysema [1]
Musculoskeletal	Pain affected by movement, local tenderness [1,2]

Management Algorithm

1. For high-risk patients 1, 2, 6:

   • Activate emergency protocols (STEMI, aortic dissection)
   • Immediate hospital admission
   • For STEMI: Primary PCI within 120 minutes (reduces mortality from 9% to 7%) 6
   • If PCI not available within 120 minutes: Fibrinolytic therapy followed by transfer 6

2. For intermediate-risk patients 2, 6:

   • Admission for observation and serial troponins
   • Consider early invasive strategy (within 24-48 hours) for NSTE-ACS
   • Further risk stratification with stress testing or imaging

3. For low-risk patients 1, 2:

   • May not need urgent diagnostic testing
   • Consider observation unit admission if additional testing needed
   • Discharge with follow-up if serial troponins negative, normal ECG, and symptoms resolved

Common Pitfalls to Avoid 2:

• Relying solely on ECG to rule out ACS
• Using nitroglycerin response as a diagnostic test
• Discharging patients with ongoing symptoms
• Forgetting about non-cardiac life-threatening causes
• Underdiagnosing women and elderly patients with atypical presentations

Key Points

• Musculoskeletal pain is the most prevalent cause of chest pain (cardiac problems account for only 10-34%) 1
• High-sensitivity troponins are preferred for diagnosing acute myocardial infarction 1
• Clinical decision pathways should be used routinely in emergency department and outpatient settings 1
• Patients at intermediate risk benefit most from cardiac imaging and testing 1