What should be done for a patient experiencing chest tightness?

Management of Chest Tightness

Patients experiencing chest tightness should immediately undergo a structured diagnostic evaluation to identify or exclude potentially life-threatening causes, including a 12-lead ECG within 10 minutes of first medical contact, focused history, targeted cardiovascular examination, and high-sensitivity troponin measurement. 1

Initial Assessment

Immediate Actions

• Obtain 12-lead ECG within 10 minutes of first medical contact
• Administer aspirin 160-325 mg (chewed) unless contraindicated
• Establish IV access if symptoms are concerning
• Administer oxygen if oxygen saturation <90% or respiratory distress is present
• Begin cardiac monitoring

Focused History

• Pain characteristics: Quality (squeezing, grip-like, suffocating, heavy), location, radiation (particularly to neck, jaw, epigastrium, or arms), severity, and duration
• Associated symptoms: Shortness of breath, diaphoresis, nausea, vomiting
• Aggravating/alleviating factors: Relation to exertion, position, respiration
• Risk factors: Previous cardiovascular disease, diabetes, hypertension, smoking, family history

Physical Examination

• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation
• Cardiovascular: Heart sounds, murmurs, signs of heart failure
• Pulmonary: Breath sounds, presence of rales, unilateral decreased breath sounds
• Vascular: Pulse differentials, signs of peripheral arterial disease

Risk Stratification

High-Risk Features (Require Immediate Action)

• ST-segment elevation or new LBBB on ECG
• ST-segment depression or dynamic T-wave changes
• Positive cardiac biomarkers
• Hemodynamic instability or arrhythmias
• Prior abnormal stress test (specificity 96%, LR 3.1) 2
• Pain radiation to both arms (specificity 96%, LR 2.6) 2

Intermediate-Risk Features

• Atypical symptoms with concerning risk factors
• Non-diagnostic ECG changes
• Negative initial troponin but symptoms <6 hours from onset

Low-Risk Features

• Non-cardiac chest pain characteristics
• Normal ECG
• Negative serial troponins
• Low risk score on risk stratification tools

Diagnostic Testing Algorithm

1. For all patients:

   • 12-lead ECG
   • High-sensitivity cardiac troponin
   • Basic metabolic panel
   • Complete blood count
   • Chest X-ray

2. For high-risk patients:

   • Immediate cardiology consultation
   • Consider urgent coronary angiography
   • Admit to cardiac care unit or telemetry

3. For intermediate-risk patients:

   • Serial troponin measurements (0,3, and 6 hours)
   • Consider coronary CT angiography (CCTA) or stress testing
   • Consider observation admission

4. For low-risk patients:

   • Consider outpatient follow-up
   • No urgent diagnostic testing needed

Specific Clinical Scenarios

Suspected Acute Coronary Syndrome

• Administer aspirin, nitrates, beta-blockers, and anticoagulation as appropriate
• Consider early invasive strategy for high-risk patients
• Women may present with more associated symptoms like jaw pain, neck pain, arm pain, and epigastric symptoms 1
• Older adults (>75 years) should be evaluated for ACS when presenting with shortness of breath, syncope, acute delirium, or unexplained falls 1

Suspected Aortic Dissection

• CT angiography is the initial imaging modality of choice
• Look for severe pain with abrupt onset, pulse differential, widened mediastinum on CXR

Suspected Pulmonary Embolism

• D-dimer testing (if low pre-test probability)
• CT pulmonary angiography if D-dimer positive or high pre-test probability
• Look for tachycardia, dyspnea, pain with inspiration

Suspected Pneumothorax

• Chest X-ray
• Look for unilateral decreased/absent breath sounds, dyspnea

Non-Cardiac Causes

• Consider asthma or other pulmonary conditions if chest tightness is associated with dyspnea 3
• Consider pneumomediastinum in young patients with chest tightness after strenuous activity 4
• Consider anxiety or stress-related chest pain, especially in patients with low cardiovascular risk 5

Risk Scoring Systems

Use validated risk scores to assist with decision-making:

• HEART Score: High-risk range (7-10) has LR of 13 for ACS; low-risk range (0-3) has LR of 0.20 2
• TIMI Score: High-risk range (5-7) has LR of 6.8 for ACS; low-risk range (0-1) has LR of 0.31 2

Common Pitfalls to Avoid

• Delayed ECG acquisition
• Premature discharge of patients with atypical presentations
• Overreliance on troponin without considering clinical context
• Missing atypical presentations, especially in women and elderly
• Failure to consider non-cardiac causes of chest pain
• Assuming chest tightness without classic "crushing" pain excludes ACS 6

Patient Education

Patients should be educated about:

• The importance of seeking immediate medical attention for chest discomfort
• Recognition of atypical symptoms like arm pain, jaw pain, shortness of breath
• The average patient with NSTEMI or prolonged rest UA delays seeking medical care for approximately 2 hours after symptom onset 6
• Women and elderly patients often present with atypical symptoms 6

Remember that many patients expect a heart attack to present with dramatic, crushing chest pain, which contributes to delays in seeking care when experiencing more subtle symptoms like chest tightness 6.