What is the workup for a patient with sudden shortness of breath and chest pain?

Workup for Sudden Shortness of Breath and Chest Pain

The initial workup for a patient with sudden shortness of breath and chest pain must include a 12-lead ECG within 10 minutes of presentation, cardiac troponin measurement, focused cardiovascular examination, and chest radiography to rapidly identify life-threatening causes. 1, 2

Initial Assessment (First 10 Minutes)

History Taking

• Obtain focused history including:
  • Characteristics of chest pain: location, radiation, quality, severity, duration
  • Precipitating/alleviating factors
  • Associated symptoms (diaphoresis, nausea, vomiting, syncope)
  • Risk factors for cardiovascular disease
  • Previous cardiac history

Physical Examination

• Vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation, temperature
• Cardiovascular: heart sounds, murmurs, gallops, rubs
• Pulmonary: breath sounds, wheezing, crackles, pleural rubs
• Extremities: pulse differentials, edema, signs of deep vein thrombosis

Immediate Diagnostic Tests

1. 12-lead ECG (within 10 minutes of arrival)

   • Look for ST-segment elevation/depression, T-wave inversions, Q waves
   • Consider supplemental leads V7-V9 if initial ECG is non-diagnostic but suspicion for ACS remains high 1

2. Cardiac biomarkers

   • High-sensitivity troponin preferred
   • Serial measurements at 0,1-3 hours (high-sensitivity) or 3-6 hours (conventional) 2

3. Chest radiography

   • Evaluate for cardiomegaly, pulmonary edema, pneumonia, pneumothorax, widened mediastinum 1, 2

Differential Diagnosis Based on Clinical Presentation

Cardiac Causes

• Acute Coronary Syndrome: Diaphoresis, tachypnea, tachycardia, hypotension, S3, murmurs
• Pericarditis: Fever, pleuritic pain worse in supine position, friction rub
• Myocarditis: Fever, heart failure signs, S3

Vascular Causes

• Aortic Dissection: Severe pain with abrupt onset, pulse differential, widened mediastinum on CXR
• Pulmonary Embolism: Tachycardia + dyspnea (>90%), pain with inspiration

Pulmonary Causes

• Pneumothorax: Unilateral decreased/absent breath sounds
• Pneumonia: Fever, localized chest pain, friction rub, regional dullness to percussion

Gastrointestinal Causes

• Esophageal Rupture: Emesis, subcutaneous emphysema
• Esophagitis/PUD: Epigastric tenderness

Musculoskeletal Causes

• Costochondritis: Tenderness of costochondral joints

Risk Stratification

Based on initial assessment, stratify patients into:

1. High-risk features (immediate intervention required):

   • Hemodynamic instability
   • Ongoing chest pain
   • ST-segment elevation
   • New LBBB
   • Dynamic ECG changes
   • Elevated troponin
   • Heart failure
   • Ventricular arrhythmias

2. Intermediate-risk features:

   • History of CAD
   • Multiple cardiovascular risk factors
   • Age >75 with atypical symptoms
   • Abnormal but non-diagnostic ECG

3. Low-risk features:

   • Normal ECG
   • Negative troponin
   • Alternative diagnosis established

Further Diagnostic Testing

For High-Risk Patients

• Continuous cardiac monitoring
• Transthoracic echocardiography
• Consider CT angiography if aortic dissection or PE suspected
• Prepare for possible cardiac catheterization

For Intermediate-Risk Patients

• Serial ECGs and troponin measurements
• Consider stress testing or coronary CT angiography
• Consider echocardiography

For Low-Risk Patients

• Consider validated risk scores (HEART, TIMI, EDACS) 2
• Consider discharge with outpatient follow-up if serial troponins negative

Management During Workup

• Oxygen if saturation <90% or respiratory distress
• IV access
• Aspirin 160-325 mg (chewed) unless contraindicated
• Pain control (consider morphine for suspected ACS)
• Nitroglycerin for suspected cardiac ischemia
• Beta-blockers for tachycardia/hypertension with suspected ischemia 1

Special Considerations

• Elderly patients: Consider ACS even with atypical presentations (shortness of breath, syncope, delirium, unexplained falls) 1, 2
• Women: Higher risk of underdiagnosis; consider cardiac causes even with atypical symptoms 1
• Language barriers: Use formal translation services 1, 2

Common Pitfalls to Avoid

1. Describing chest pain as "atypical" rather than cardiac, possibly cardiac, or noncardiac 1
2. Relying solely on pain relief with nitroglycerin for diagnosis of cardiac ischemia 1
3. Delaying ECG beyond 10 minutes in patients with acute chest pain 1, 2
4. Failing to obtain serial troponins at appropriate intervals 2
5. Discharging elderly patients with atypical symptoms without adequate evaluation 1

Remember that the history and physical examination remain crucial diagnostic tools, with studies showing that 76% of diagnoses are made from the medical history alone 3.