What is the approach to evaluating and managing a patient with chest pain on the ward?

Approach to Chest Pain on the Ward

The initial evaluation of a patient with chest pain on the ward should focus on rapidly identifying life-threatening causes, determining clinical stability, and assessing the need for hospitalization versus outpatient management. 1

Initial Assessment (First 10 Minutes)

• Obtain a 12-lead ECG within 10 minutes of presentation to identify STEMI or other concerning ECG findings suggestive of ischemia 1
• Assess vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature) to identify hemodynamic instability 1
• Perform focused physical examination looking for:
  • Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, or murmurs (suggesting ACS) 1
  • Pulse differentials between extremities (suggesting aortic dissection) 1
  • Unilateral decreased breath sounds (suggesting pneumothorax or pleural effusion) 1
  • Tenderness of costochondral joints (suggesting costochondritis) 1

Immediate Management

• For suspected ACS or other life-threatening causes of chest pain, initiate urgent transfer to the ED, ideally by EMS 1
• Provide pain relief with morphine titrated intravenously according to pain severity 1
• Administer sublingual nitroglycerin for suspected ischemic chest pain 1, 2
  • Caution: Avoid in patients with hypotension, recent PDE-5 inhibitor use, or right ventricular infarction 2
• Consider beta-blockers (e.g., metoprolol) for tachycardia and hypertension if myocardial ischemia is suspected 1, 3
• Obtain cardiac biomarkers (high-sensitivity troponin preferred) as soon as possible 1

Differential Diagnosis

Life-Threatening Causes:

1. Acute Coronary Syndrome (ACS)

   • Characterized by chest pressure, tightness, or discomfort that may radiate to shoulders, arms, neck, back, or jaw 1
   • May be accompanied by diaphoresis, nausea, dyspnea 1

2. Aortic Dissection

   • Severe, abrupt-onset pain with pulse differential between extremities (30% of patients) 1
   • Higher risk in patients with connective tissue disorders (e.g., Marfan syndrome) 1
   • Widened mediastinum on chest X-ray increases probability 1

3. Pulmonary Embolism

   • Tachycardia and dyspnea in >90% of patients 1
   • Pain often worsens with inspiration 1

4. Pneumothorax

   • Dyspnea and pain on inspiration with unilateral absence of breath sounds 1

5. Esophageal Rupture

   • History of emesis, subcutaneous emphysema, pneumothorax in 20% of patients 1

Other Important Causes:

• Pericarditis: Pleuritic chest pain, worse when supine, friction rub on exam 1
• Myocarditis: Fever, chest pain, signs of heart failure 1
• Pneumonia: Fever, localized chest pain, regional dullness to percussion 1
• Musculoskeletal pain: Most common final diagnosis in primary care (33.1%) 4

Risk Stratification

High Risk Features:

• ECG changes suggestive of ischemia (ST elevation, depression, T-wave inversion) 1
• Elevated cardiac biomarkers 1
• Hemodynamic instability (hypotension, tachycardia) 1
• History of coronary artery disease 5
• Typical anginal symptoms 5
• Multiple episodes of pain in the last 24 hours 5
• Age ≥55 years, male sex, diabetes, family history of CAD 5

Low Risk Features:

• Normal ECG 5
• Normal cardiac biomarkers 5
• <2 risk factors: age <55, non-typical pain, single episode, no diabetes, no family history 5

Diagnostic Testing

• ECG: Obtain and interpret within 10 minutes of presentation 1
• Cardiac biomarkers: High-sensitivity troponin preferred 1
  • For patients with acute chest pain and suspected ACS, measure troponin as soon as possible 1
  • Consider serial measurements at 0/1-hour or 0/3-hour intervals depending on assay 1
• Chest X-ray: Helpful to identify pneumonia, pneumothorax, widened mediastinum 1
• Additional testing based on clinical suspicion:
  • Echocardiography for suspected structural heart disease, wall motion abnormalities 1
  • CT angiography for suspected aortic dissection or pulmonary embolism 1
  • Stress testing for intermediate-risk patients with negative initial workup 1

Disposition Decision-Making

• Patients with STEMI, high-risk NSTEMI, or other life-threatening conditions require immediate transfer to higher level of care 1
• Intermediate-risk patients may benefit from observation and serial troponin testing 1
• Low-risk patients (negative ECG, negative troponins, <2 risk factors) may not need urgent diagnostic testing 1, 5

Common Pitfalls to Avoid

• Delaying ECG acquisition beyond 10 minutes in patients with acute chest pain 1
• Relying solely on a single troponin measurement rather than using serial measurements 1
• Failing to consider non-cardiac causes of chest pain, which are actually more common in primary care settings 4
• Discharging patients with concerning features without appropriate follow-up or additional testing 5
• Overlooking atypical presentations in women, elderly, and patients with diabetes who may present with less typical symptoms 1

By following this systematic approach to chest pain evaluation on the ward, clinicians can efficiently identify patients requiring urgent intervention while appropriately risk-stratifying others for further testing or safe discharge.