What is the workup for a patient presenting with chest tightness?

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Last updated: March 22, 2025 • View editorial policy

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From the Guidelines

The workup for a patient with chest tightness should begin with a thorough history and physical examination, followed by an immediate electrocardiogram (ECG) and measurement of high-sensitivity cardiac troponins, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The initial evaluation should also include obtaining vital signs, such as blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.

  • Laboratory tests should include cardiac biomarkers (troponin, preferably high-sensitivity troponin with serial measurements at 0,3, and 6 hours), complete blood count, basic metabolic panel, and BNP if heart failure is suspected.
  • A chest X-ray can help identify pulmonary causes like pneumonia or pneumothorax.
  • If acute coronary syndrome is suspected but initial tests are negative, consider stress testing or coronary CT angiography, as suggested by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.
  • For patients with intermediate to high risk of cardiac causes, hospital admission for observation and further testing may be warranted. The urgency of the workup depends on the patient's risk factors (age, diabetes, hypertension, smoking, family history), associated symptoms (radiation to arm/jaw, diaphoresis, nausea, dyspnea), and the quality of pain, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. It is also essential to assess for non-cardiac causes of chest tightness, including gastroesophageal reflux disease, musculoskeletal pain, anxiety, pulmonary embolism, or aortic dissection, as highlighted in the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1. This systematic approach helps differentiate between life-threatening conditions requiring immediate intervention and less urgent causes of chest tightness, ultimately prioritizing morbidity, mortality, and quality of life as the outcome, as emphasized by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1 and the executive summary of the same guideline 1.

From the Research

Initial Evaluation

  • The workup for a patient presenting with chest tightness begins with an electrocardiogram (ECG) obtained within 10 minutes of presentation 2
  • If ST-segment elevation is present, ST-segment elevation MI (STEMI) is diagnosed 2
  • If STEMI is not present, troponin levels should be measured using one of several recommended protocols 2

Troponin Levels and Risk Stratification

  • Troponin levels greater than 99th percentile of the upper reference limit are consistent with acute coronary syndrome (ACS) 2
  • If the ECG finding is normal and results of two troponin tests are negative, risk stratification should be calculated using Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score 2
  • High sensitivity cardiac troponins (hs-cTns) can more rapidly detect myocardial injury, but elevations in hs-cTn can occur in patients who are not currently experiencing an acute myocardial infarction 3

Alternative Diagnoses and Further Evaluation

  • Alternative diagnoses to consider in patients with elevated troponin levels and chest pain include inflammatory or infectious conditions of the myocardium and pericardium, such as myopericarditis 4
  • Further evaluation to exclude coronary artery disease (CAD) may include exercise treadmill testing, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography 2
  • Cardiac MRI (CMR) imaging can provide detailed structural information of the heart and is the gold standard modality of investigation to confirm the diagnosis and rule out underlying pathology 4

Decision Aids and Triage

  • The History and Electrocardiogram-only Manchester Acute Coronary Syndromes (HE-MACS) decision aid can be used to risk stratify patients at triage using only the history, physical examination, and ECG 5
  • HE-MACS can identify patients as "very low risk" and potentially rule out ACS in a subset of patients, while effectively risk stratifying remaining patients 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Research

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid.

European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 2019

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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