What is the appropriate initial assessment and management plan for a patient presenting with chest pain?

Initial Assessment and Management of Chest Pain

A focused cardiovascular examination should be performed immediately for all patients presenting with chest pain to aid in the diagnosis of acute coronary syndrome (ACS) or other potentially serious causes such as aortic dissection, pulmonary embolism (PE), or esophageal rupture. 1

Initial Evaluation Steps

1. Immediate ECG (within 10 minutes)

   • An ECG should be acquired and reviewed within 10 minutes of arrival for all patients with acute chest pain 1, 2
   • If unavailable in office setting, refer patient to ED 1
   • Consider supplemental ECG leads (V7-V9) if clinical suspicion remains high despite normal standard ECG 2

2. Vital Signs and Physical Examination

   • Look for specific findings that suggest life-threatening conditions:
     • ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, mitral regurgitation murmur 1
     • Pulmonary Embolism: Tachycardia + dyspnea (>90% of patients), pain with inspiration 1
     • Aortic Dissection: Pulse differential (30% of patients), severe pain with abrupt onset 1, 2
     • Pneumothorax: Unilateral absence of breath sounds, dyspnea 1
     • Pericarditis: Friction rub, pain worse in supine position 1

3. Laboratory Testing

   • Cardiac troponin measurement as soon as possible for suspected ACS 1, 2
   • Serial troponin measurements to identify rising/falling patterns 2

4. Imaging

   • Chest X-ray within 30 minutes of arrival 2
   • Consider transthoracic echocardiography to evaluate ventricular function, wall motion abnormalities, and pericardial effusion 2

Risk Stratification

High-Risk Features (Immediate ED Referral)

• Clinical evidence of ACS or other life-threatening causes 1
• ST-segment elevation or new-onset left bundle branch block on ECG 2
• Hemodynamic instability or respiratory distress 1
• Ripping chest pain ("worst pain of life"), especially with hypertension or known aortic valve disease 1

Moderate-Risk Features

• Chest pain with exertion 2
• Pain radiating to arm(s), jaw, neck, or back 2
• Associated symptoms: dyspnea, diaphoresis, nausea/vomiting 1, 2
• Abnormal but non-diagnostic ECG changes 1

Low-Risk Features

• Non-exertional pain 2
• Pain reproducible with palpation 3
• Brief duration of symptoms 2
• Normal vital signs, ECG, and chest X-ray 2

Management Algorithm

1. For High-Risk Patients:

   • Immediate transport to ED, preferably by EMS 1, 2
   • Administer aspirin 160-325 mg (chewed) if no contraindications 2
   • Oxygen if saturation <90% or respiratory distress 2
   • Establish IV access 2

2. For Moderate-Risk Patients:

   • If in office setting: ECG and referral to ED for further evaluation 1
   • Consider risk stratification tools (HEART Score, TIMI Risk Score) 2
   • Avoid delayed transfer to ED for troponin testing 1

3. For Low-Risk Patients:

   • Consider outpatient evaluation with exercise stress testing, coronary CT angiography, or cardiac MRI 4, 3
   • Evaluate for non-cardiac causes (GERD, musculoskeletal pain, anxiety) 4

Special Considerations

• Elderly Patients (≥75 years): Consider ACS even with atypical presentations like shortness of breath, syncope, or acute delirium 2
• Women and Diabetic Patients: May present with atypical symptoms 2
• Language Barriers: Use formal translation services 2

Common Pitfalls to Avoid

1. Relying solely on chest pain characteristics: Normal examination does not exclude serious pathology, especially in uncomplicated ACS 1

2. Delayed ECG acquisition: Failure to obtain an ECG within 10 minutes can delay diagnosis of STEMI 1

3. Premature discharge: Low-risk patients still require appropriate follow-up and may benefit from observation 5

4. Overlooking non-coronary causes: Remember to consider aortic dissection, PE, pneumothorax, and other life-threatening conditions 1, 2

5. Dismissing reproducible chest pain: While pain reproducible by palpation suggests musculoskeletal origin, it does not completely exclude cardiac causes 3