What diagnostic tests are suggested for a patient presenting with chest pressure?

Diagnostic Tests for Chest Pressure

For patients presenting with chest pressure, the initial diagnostic workup should include a 12-lead ECG within 10 minutes of first medical contact, focused history, targeted cardiovascular examination, and high-sensitivity troponin measurement to rapidly identify or exclude potentially life-threatening causes. 1

Initial Evaluation

Immediate Tests (First 10 Minutes)

• 12-lead ECG: Must be performed within 10 minutes of first medical contact 2, 1
• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation
• High-sensitivity cardiac troponin (hs-cTn): Initial measurement with follow-up testing based on protocol 2, 1

Focused History Elements

• Pain characteristics: location, radiation, quality, severity, duration
• Aggravating/alleviating factors
• Associated symptoms (diaphoresis, nausea, dyspnea, etc.)
• Cardiovascular risk factors
• Previous cardiac history

Risk Stratification

After initial assessment, patients should be stratified using validated risk scores:

• HEART score (History, ECG, Age, Risk factors, Troponin)
• TIMI risk score (Thrombolysis In Myocardial Infarction)
• GRACE risk score (Global Registry of Acute Coronary Events) 1

Diagnostic Algorithm Based on Risk Level

High-Risk Features

• ST-segment elevation or new LBBB
• Hemodynamic instability
• Ongoing chest pain
• Positive cardiac biomarkers
• High-risk score on risk stratification tools
• ECG changes concerning for ischemia
• Signs of heart failure 1

Recommended Tests for High-Risk Patients:

1. Immediate cardiology consultation
2. Coronary angiography if ST-elevation MI or high-risk ACS
3. Transthoracic echocardiography to evaluate ventricular and valvular function, detect wall motion abnormalities, and identify pericardial effusion 2, 1
4. CT angiography if aortic dissection is suspected 2
5. Serial troponin measurements (if initial is negative)

Intermediate-Risk Features

• Atypical symptoms but concerning risk factors
• Non-diagnostic ECG changes
• Negative initial troponin but symptoms <6 hours from onset
• Intermediate risk score on stratification tools 1

Recommended Tests for Intermediate-Risk Patients:

1. Serial ECGs and troponins (0h/1h algorithm with additional measurement at 3h if inconclusive) 1
2. Chest X-ray to exclude pulmonary causes 2
3. Transthoracic echocardiography - especially valuable in patients with known underlying cardiac disease (valvular, pericardial, or primary myocardial disease) 2
4. Non-invasive cardiac testing before discharge:
   • Coronary CT angiography (CCTA) - preferred for patients without known CAD 2, 1
   • Stress testing options:
     • Exercise stress test
     • Stress echocardiography
     • Myocardial perfusion imaging 1

Low-Risk Features

• Non-cardiac chest pain characteristics
• Normal ECG
• Negative serial troponins
• Low risk score on stratification tools
• Alternative diagnosis established
• Resolution of symptoms 1

Recommended Tests for Low-Risk Patients:

• No urgent diagnostic testing is needed for patients determined to be low risk 2, 1
• Consider outpatient follow-up with primary care provider

Special Considerations for Specific Conditions

Suspected Aortic Dissection

• CT angiography is the initial imaging modality of choice 2
• Transoesophageal echocardiography may be considered if CT is not available or in unstable patients 2

Suspected Pulmonary Embolism

• CT pulmonary angiography (CTPA) is the primary imaging modality 2
• D-dimer testing (negative result can exclude PE in low/intermediate probability patients) 2
• V/Q scan if CTPA is contraindicated 2

Suspected Pericardial Disease

• Transthoracic echocardiography to evaluate for effusion, constriction, or effusive-constrictive process 2

Common Pitfalls to Avoid

1. Delayed ECG acquisition - must be obtained within 10 minutes of first medical contact
2. Premature discharge - 2-5% of ACS patients are inappropriately discharged from the ED 3
3. Overreliance on troponin - normal troponin doesn't exclude ACS in early presenters
4. Missing atypical presentations - especially in women, elderly, and diabetic patients
5. Failure to consider non-cardiac causes - such as pulmonary embolism, aortic dissection, or pneumothorax

By following this systematic approach to diagnostic testing for chest pressure, clinicians can efficiently identify life-threatening conditions while avoiding unnecessary testing in low-risk patients.