What is the initial management protocol for a patient presenting with chest pain?

Initial Management Protocol for Chest Pain

The initial management of a patient presenting with chest pain should include a focused history, ECG within 10 minutes of arrival, cardiac troponin measurement, and immediate activation of emergency services for suspected life-threatening conditions. 1

Immediate Assessment and Triage

• For patients with severe, prolonged chest pain of acute onset, immediate hospital care is needed as this could indicate potentially life-threatening conditions such as heart attack, unstable angina, aortic dissection, pulmonary embolism, or pneumothorax 1
• A 12-lead ECG should be obtained and reviewed within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 1
• Cardiac troponin should be measured as soon as possible after presentation for patients with suspected acute coronary syndrome (ACS) 1
• Patients with clinical evidence of ACS or other life-threatening causes of chest pain seen in an office setting should be transported urgently to the emergency department, ideally by emergency medical services (EMS) 1

History and Physical Examination

• Obtain a focused history including characteristics and duration of symptoms, associated features, and cardiovascular risk factor assessment 1

• Key elements to assess in the history include:

  • Nature of pain (retrosternal discomfort, heaviness, pressure, squeezing) 1
  • Onset and duration (gradual build over minutes suggests angina) 1
  • Location and radiation (radiation to left arm, neck, jaw suggests cardiac origin) 1
  • Precipitating factors (physical/emotional stress) 1
  • Relieving factors 1
  • Associated symptoms (dyspnea, nausea, lightheadedness) 1

• Indicators of potentially serious conditions include:

  • Interruption of normal activity 1
  • Accompanying cold sweat, nausea, vomiting, fainting, anxiety/fear 1
  • Prior abnormal stress test, peripheral arterial disease, and pain radiation to both arms (these findings are highly specific for ACS) 2

Initial Interventions

• For suspected heart attack:

  • Administer fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible 1
  • Consider short-acting nitrates if there is no bradycardia or hypotension 1
  • Consider opiates to relieve pain and anxiety 1
  • Monitor vital signs and cardiac rhythm continuously 1

• For all patients with chest pain:

  • Place on cardiac monitor immediately with emergency resuscitation equipment nearby 1
  • Have a defibrillator readily available 1
  • Obtain intravenous access 1
  • Consider supplemental oxygen for hypoxemic patients 1

Diagnostic Testing

• ECG findings most suggestive of ACS include ST-segment depression (specificity 95%) and any evidence of ischemia (specificity 91%) 2
• If the initial ECG is nondiagnostic but clinical suspicion for ACS remains high, perform serial ECGs to detect potential ischemic changes 1
• Supplemental ECG leads V7-V9 are reasonable to rule out posterior myocardial infarction when initial ECG is nondiagnostic 1
• Chest radiography is useful to evaluate for other potential cardiac, pulmonary, or thoracic causes of chest pain 1

Risk Stratification

• Risk scores incorporating history, ECG, age, risk factors, and troponin (such as HEART or TIMI) provide valuable diagnostic information 2
• The HEART score (0-3) and TIMI score (0-1) in their low-risk ranges are useful for identifying patients less likely to have ACS 2
• High-risk features warranting immediate attention include:
  • Recurrent ischemia (recurrent chest pain or dynamic ST-segment changes) 1
  • Elevated troponin levels 1
  • Hemodynamic instability 1
  • Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
  • Diabetes mellitus 1

Common Pitfalls and Caveats

• Physical examination contributes minimally to diagnosing heart attack unless there is associated shock 1
• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia, as other conditions (e.g., esophageal spasm) may show comparable response 1
• There is frequently a lack of correlation between intensity of symptoms and seriousness of disease 1
• Patients often delay seeking medical attention for chest pain (median 60 minutes), with longer delays in older patients and those in rural areas 1
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, lightheadedness, or vague abdominal symptoms 1
• Avoid delayed transfer to the emergency department for cardiac troponin or other diagnostic testing for patients initially evaluated in an office setting 1

Disposition

• Patients with STEMI or high-risk features should be treated according to ACS guidelines with consideration for immediate reperfusion therapy 1
• For intermediate to low-risk patients, further risk stratification with additional testing (stress testing, coronary CT angiography) may be appropriate 3
• Patients with non-cardiac causes of chest pain should be treated according to the specific diagnosis 1