What is the next step in diagnosis and treatment for an 80-year-old female presenting with sudden onset chest pain to the Emergency Department (ED)?

From the Guidelines

The immediate next steps for an 80-year-old female presenting with sudden onset chest pain to the Emergency Department should focus on rapid assessment and stabilization, including obtaining vital signs, placing the patient on continuous cardiac monitoring, establishing IV access, and administering supplemental oxygen if oxygen saturation is low, as recommended by the 2024 American Heart Association guidelines 1. The patient should undergo an immediate 12-lead ECG to evaluate for acute coronary syndrome, particularly ST-elevation myocardial infarction (STEMI), which would require immediate reperfusion therapy.

• Key considerations include:
  • Drawing blood for cardiac biomarkers (troponin), complete blood count, basic metabolic panel, coagulation studies, and type and screen.
  • Administering aspirin 325 mg chewed (unless contraindicated) as it improves survival in patients with myocardial infarction, according to the 2024 American Heart Association guidelines 1.
  • Considering nitroglycerin 0.4 mg sublingual for ongoing pain if blood pressure allows.
  • Obtaining a portable chest X-ray to evaluate for other causes such as aortic dissection, pneumothorax, or pulmonary pathology.
  • Considering a broader differential including pulmonary embolism, which may require CT pulmonary angiography if suspected, as suggested by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The approach should prioritize identifying and addressing the most life-threatening causes of chest pain while establishing the diagnosis to guide further management, with a focus on patient-centered care and shared decision-making, as emphasized in the 2021 guideline 1.
• Important aspects of care include:
  • Using high-sensitivity troponins for biomarker diagnosis of acute myocardial infarction.
  • Implementing clinical decision pathways for chest pain in the emergency department.
  • Estimating risk for coronary artery disease and adverse events using evidence-based diagnostic protocols.
  • Providing patient education and involving the patient in decision-making processes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Diagnosis and Treatment

The next steps in diagnosis and treatment for an 80-year-old female presenting with sudden onset chest pain to the Emergency Department (ED) involve:

• Obtaining an immediate 12-lead electrocardiogram (ECG) to identify ST-elevation myocardial infarction (STEMI) 2
• Measuring troponin levels using one of several recommended protocols to diagnose acute coronary syndrome (ACS) 3
• If the ECG finding is normal and results of two troponin tests are negative, calculating risk stratification using Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score 3
• Considering alternative diagnoses such as inflammatory or infectious conditions of the myocardium and pericardium, particularly if the patient has a very high troponin level 4

Diagnostic Evaluation

The diagnostic evaluation for the patient should include:

• A thorough history and physical examination to identify high-risk features and symptoms suggestive of ACS 3
• An ECG to identify STEMI or other ischemic changes 2, 3
• Measurement of cardiac enzymes such as troponin and CK-MB to diagnose ACS 5, 6
• Consideration of further evaluation using exercise treadmill testing, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography to exclude coronary artery disease (CAD) 3

Considerations for Older Adults

For older adults, such as the 80-year-old female in this scenario, it is essential to consider the following:

• The patient's age and presenting symptoms, such as abdominal pain or nausea/vomiting, which may be atypical symptoms of ACS 2
• The importance of obtaining an immediate ECG to identify STEMI, even if the patient does not present with chest pain 2
• The need for careful risk stratification and further evaluation to exclude CAD, as many patients with ACS are misdiagnosed 3