Initial Workup and Disposition for Chest Pain
The initial workup for a patient presenting with chest pain should include a 12-lead ECG within 10 minutes of first medical contact, focused history emphasizing pain characteristics and associated symptoms, targeted cardiovascular examination, and high-sensitivity troponin measurement to rapidly identify or exclude potentially life-threatening causes. 1, 2
Initial Assessment
History
- Obtain a focused history including:
- Pain characteristics (location, quality, radiation, severity, duration)
- Aggravating/alleviating factors
- Associated symptoms (shortness of breath, diaphoresis, nausea, syncope)
- Cardiovascular risk factors
- Previous cardiac history
- Timing relative to presentation 1
Physical Examination
- Perform targeted cardiovascular examination to detect:
- Vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
- Heart sounds (murmurs, gallops, rubs)
- Lung examination (crackles, wheezes, decreased breath sounds)
- Signs of heart failure (JVD, peripheral edema)
- Pulse differentials (aortic dissection) 1
Immediate Diagnostic Testing
- 12-lead ECG within 10 minutes of first medical contact 1, 2
- Blood sampling for high-sensitivity cardiac troponin (hs-cTn) 1, 2
- Chest X-ray if pulmonary or other non-cardiac causes are suspected 1
Risk Stratification
Use validated risk scores such as:
Consider patient demographics:
- For women: Be aware they may present with more associated symptoms (jaw pain, neck pain, arm pain, palpitations, epigastric symptoms) 1
- For older adults (>75 years): Consider ACS when accompanying symptoms like shortness of breath, syncope, acute delirium, or unexplained falls are present 1
Disposition Algorithm
High-Risk Features (Immediate Hospitalization)
- ST-segment elevation or new LBBB
- Hemodynamic instability
- Ongoing chest pain
- Positive cardiac biomarkers
- High-risk score on risk stratification tools
- Concerning ECG changes (ST depression, T-wave inversions)
- Signs of heart failure 1, 2
Intermediate-Risk Features (Observation Unit)
- Atypical symptoms but concerning risk factors
- Non-diagnostic ECG changes
- Negative initial troponin but symptoms <6 hours from onset
- Intermediate risk score on risk stratification tools 1, 2
Low-Risk Features (Potential Discharge)
- Non-cardiac chest pain characteristics
- Normal ECG
- Negative serial troponins (0h and 1-3h)
- Low risk score on risk stratification tools
- Alternative diagnosis established
- Resolution of symptoms 1, 2, 3
Additional Testing Based on Risk Level
High-Risk Patients
- Immediate cardiology consultation
- Consideration for urgent coronary angiography
- Admission to cardiac care unit or telemetry 1, 2
Intermediate-Risk Patients
- Serial ECGs and troponins
- Consider non-invasive cardiac testing before discharge:
Low-Risk Patients
- Consider discharge with outpatient follow-up
- May consider early non-invasive testing in selected cases 3, 4
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 with atypical presentations
- Failing to obtain serial ECGs in patients with persistent symptoms 2
Cultural and Language Considerations
- Cultural competency training is recommended to help achieve optimal outcomes in diverse patient populations 1
- Use formal translation services for patients with language barriers 1
Emergency Medical Services Activation
For patients with acute chest pain in the community, immediate activation of emergency medical services (9-1-1) is recommended for transport to the closest emergency department 1
Remember that chest pain evaluation requires a systematic approach to identify potentially life-threatening conditions quickly while avoiding unnecessary admissions for low-risk patients who can be safely discharged.