What is the initial approach to a patient presenting with chest pain?

Initial Approach to Chest Pain

The initial approach to a patient with chest pain should include a focused history of pain characteristics, a cardiovascular examination, and a 12-lead ECG within 10 minutes of arrival to identify potentially life-threatening causes and guide appropriate management. 1

Initial Assessment

Immediate Evaluation

1. Vital signs assessment
2. 12-lead ECG within 10 minutes of arrival 1, 2
3. Focused cardiovascular examination 1
4. Cardiac biomarkers (high-sensitivity troponin preferred) 2

History Taking

When evaluating chest pain, focus on:

• Pain characteristics: Quality, location, radiation, duration, severity
• Timing: Onset, duration relative to presentation
• Precipitating factors: Exertion, stress, position changes
• Relieving factors: Rest, nitroglycerin, position changes
• Associated symptoms: Dyspnea, diaphoresis, nausea, syncope 1

Do not describe chest pain as "atypical" as this can be misinterpreted as benign. Instead, categorize as cardiac, possibly cardiac, or noncardiac based on characteristics. 1

High-Risk Features Requiring Immediate Action

• Ongoing chest pain with ECG changes
• Hemodynamic instability
• Troponin elevation
• Severe sudden-onset "tearing" pain (aortic dissection)
• Chest pain with syncope, acute dyspnea, or hypoxemia 2

Risk Stratification

High Probability of Cardiac Ischemia

• Central/left-sided chest pressure, heaviness, or squeezing
• Pain radiating to jaw, neck, or left arm
• Associated with exertion
• Associated with diaphoresis, nausea, or dyspnea
• History of coronary artery disease 1

Special Considerations

• Women: More likely to present with accompanying symptoms like shortness of breath, fatigue, and nausea rather than classic chest pain 1
• Elderly (≥75 years): Consider ACS when presenting with shortness of breath, syncope, acute delirium, or unexplained falls 1

Diagnostic Approach

ECG Interpretation

• Immediately review for ST-segment elevation (STEMI)
• Look for ST depression, T-wave inversions, or other ischemic changes
• Compare with previous ECGs if available
• Consider serial ECGs if symptoms persist 1, 2

Laboratory Testing

• Cardiac biomarkers (high-sensitivity troponin)
• Complete blood count
• Basic metabolic panel
• Chest radiography 2

Differential Diagnosis

Life-Threatening Causes

1. Acute Coronary Syndrome

   • Diaphoresis, tachypnea, tachycardia; exam may be normal 2

2. Aortic Dissection

   • Severe pain with abrupt onset, pulse differential, widened mediastinum on CXR 2

3. Pulmonary Embolism

   • Tachycardia, dyspnea (>90%), pain with inspiration 2

4. Pneumothorax

   • Unilateral decreased/absent breath sounds, dyspnea 2

5. Pericarditis

   • Fever, pleuritic pain worse in supine position, friction rub 2

6. Esophageal Rupture

   • Emesis, subcutaneous emphysema 2

Common Non-Life-Threatening Causes

• Musculoskeletal pain (most prevalent cause, >60% of cases) 2
• Gastroesophageal reflux disease
• Anxiety/panic disorder

Initial Management

For Suspected Cardiac Chest Pain

1. Oxygen: If oxygen saturation <90% or respiratory distress 2
2. IV access: Establish in patients with concerning symptoms 2
3. Nitroglycerin: 0.4 mg sublingual every 5 minutes for up to 3 doses for ongoing ischemic discomfort 2, 3
   • Patient should sit when taking nitroglycerin to prevent falls from lightheadedness 3
   • Contraindicated with recent PDE-5 inhibitor use (Viagra, Cialis, Levitra) 3
4. Aspirin: 160-325 mg (chewed) unless contraindicated 2

Disposition Decision

Emergency Department Referral

• Patients with high-risk features
• Intermediate risk features with concerning symptoms
• ECG changes or elevated troponin 2

Outpatient Management

• Low-risk features
• Normal ECG
• Alternative diagnosis likely
• Resolved symptoms 2

Common Pitfalls to Avoid

• Relying solely on ECG to rule out ACS
• Using nitroglycerin response as a diagnostic test
• Discharging patients with ongoing symptoms
• Underdiagnosing women and elderly patients with atypical presentations 2
• Failing to obtain serial ECGs in patients with persistent symptoms 2

By following this systematic approach to chest pain evaluation, clinicians can effectively identify patients with life-threatening conditions requiring immediate intervention while appropriately managing those with less serious causes.