What is the initial workup and treatment for a patient presenting with chest pain?

Initial Workup and Treatment for Chest Pain

The initial workup for a patient presenting with chest pain should include a focused history, physical examination, 12-lead ECG within 10 minutes of arrival, and cardiac troponin measurement to identify life-threatening conditions such as acute coronary syndrome, pulmonary embolism, or aortic dissection. 1, 2

Immediate Assessment and Triage

• Obtain a 12-lead ECG within 10 minutes of arrival to identify STEMI or other acute coronary syndromes 1
• Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby 2
• Measure cardiac troponin as soon as possible for patients with suspected acute coronary syndrome 1, 2
• If in an office setting with clinical evidence of ACS or other life-threatening causes of chest pain, arrange urgent transport to the emergency department, ideally by EMS 1, 2
• If an ECG cannot be obtained in the office setting, transfer to the ED should be initiated 1

Focused History

• Obtain a comprehensive history including characteristics and duration of symptoms, associated features, and cardiovascular risk factor assessment 1, 2
• Key elements to assess include:
  • Nature of pain (retrosternal discomfort, heaviness, pressure, squeezing) 1
  • Onset and duration (gradual build over minutes suggests angina) 1
  • Location and radiation (pain localized to a very limited area is unlikely to be ischemic) 1
  • Precipitating factors (physical/emotional stress) 1
  • Relieving factors (rest, nitroglycerin) 1
  • Associated symptoms (diaphoresis, nausea, dyspnea) 1, 2

Physical Examination

• Perform a focused cardiovascular examination to aid in diagnosis of ACS or other serious causes of chest pain 1
• Look for specific findings that may indicate:
  • ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, mitral regurgitation murmur 1
  • Aortic dissection: Pulse differential between extremities, widened mediastinum on chest x-ray 1
  • Pulmonary embolism: Tachycardia, dyspnea, pain with inspiration 1
  • Pericarditis: Friction rub, increased pain in supine position 1
  • Pneumothorax: Unilateral absence of breath sounds 1

Diagnostic Testing

• If initial ECG is nondiagnostic but clinical suspicion for ACS remains high, perform serial ECGs to detect potential ischemic changes 1
• Consider supplemental ECG leads V7-V9 to rule out posterior MI when initial ECG is nondiagnostic 1
• Obtain chest radiography to evaluate for other potential cardiac, pulmonary, or thoracic causes of chest pain 2
• For patients with suspected pulmonary embolism, consider appropriate diagnostic testing based on clinical risk assessment 1

Initial Treatment

• For suspected ACS:
  • Administer aspirin (250-500 mg, chewable or water-soluble) as soon as possible 2
  • Consider short-acting nitrates if there is no bradycardia or hypotension 2
  • For confirmed NSTE-ACS, consider dual antiplatelet therapy with aspirin and clopidogrel 3
  • For patients with confirmed ACS, consider anticoagulation with heparin 4
• Patients with STEMI or high-risk features should be treated according to ACS guidelines with consideration for immediate reperfusion therapy 1, 2
• For non-cardiac causes of chest pain, treatment should be directed at the specific diagnosis 2

Risk Stratification

• High-risk features warranting immediate attention include:
  • Recurrent ischemia
  • Elevated troponin levels
  • Hemodynamic instability
  • Major arrhythmias
  • Diabetes mellitus 2
• Low-risk patients with chest pain and no evidence of myocardial infarction may be safely discharged after appropriate evaluation 5

Common Pitfalls and Caveats

• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia, as other conditions may show comparable response 2
• There is frequently a lack of correlation between intensity of symptoms and seriousness of disease 1, 2
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, or vague abdominal symptoms 2
• Up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG, highlighting the importance of serial ECGs and cardiac biomarkers 1
• Pre-hospital ECG for patients with chest pain minimally prolongs scene and transport times but can significantly reduce door-to-balloon time for STEMI patients 6