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

Initial Workup for Chest Pain

For patients presenting with chest pain, the initial workup should include a focused history, physical examination, 12-lead ECG within 10 minutes of arrival, and cardiac troponin measurement as soon as possible to identify life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection, or esophageal rupture.1, 2

Immediate Assessment and Triage

• Activate 9-1-1 for patients with acute chest pain to initiate transport to the closest emergency department by emergency medical services 1
• Obtain and review a 12-lead ECG within 10 minutes of arrival to identify STEMI or other acute coronary syndromes 1, 2
• Measure cardiac troponin as soon as possible in patients with suspected ACS presenting to the ED 1
• Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby 2
• If initial ECG is nondiagnostic but clinical suspicion for ACS remains high, perform serial ECGs to detect potential ischemic changes 2

Focused History

• Obtain a detailed description of chest pain characteristics including:

  • Nature (pressure, heaviness, tightness, squeezing suggest ischemia; sharp, stabbing, pleuritic suggest non-cardiac causes) 1
  • Onset and duration (sudden onset of severe pain suggests aortic dissection) 1
  • Location and radiation (central/retrosternal with radiation to arms, neck, jaw suggests cardiac origin) 1
  • Precipitating factors (exertion, stress, meals, position changes) 1
  • Relieving factors (rest, nitroglycerin - though this should not be used as a diagnostic criterion) 2
  • Associated symptoms (diaphoresis, nausea, dyspnea, syncope) 1

• Pay special attention to women's presentations, as they may have more accompanying symptoms such as nausea, shortness of breath, and pain in the jaw, neck, arms, or between shoulder blades 1

• In patients ≥75 years of age, consider ACS when accompanying symptoms such as shortness of breath, syncope, acute delirium, or unexplained falls are present 1

Physical Examination

• Perform a focused cardiovascular examination to aid in diagnosis and identify complications 1
• Key findings to assess include:
  • Vital signs (tachycardia, tachypnea, hypotension suggest emergency) 1
  • Cardiovascular exam (S3, murmurs, friction rub) 1
  • Pulmonary exam (crackles, unilateral decreased breath sounds) 1
  • Abdominal exam (epigastric tenderness, right upper quadrant tenderness) 1
  • Extremity exam (pulse differentials suggesting aortic dissection) 1
  • Chest wall tenderness (suggesting musculoskeletal causes) 1

Initial Diagnostic Testing

• 12-lead ECG (within 10 minutes of arrival) 1, 2
• Cardiac troponin measurement 1, 2
• Consider supplemental ECG leads V7-V9 to rule out posterior myocardial infarction when initial ECG is nondiagnostic 2
• Chest radiography to evaluate for other potential cardiac, pulmonary, or thoracic causes of chest pain 2

Risk Stratification

• High-risk features warranting immediate attention include:
  • ST-segment elevation or Q waves on ECG suggesting acute myocardial infarction 3
  • Other ECG changes indicating myocardial ischemia 3
  • Low systolic blood pressure 3
  • Pulmonary rales above the bases 3
  • Exacerbation of known ischemic heart disease 3
  • Recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias 2

Common Pitfalls and Caveats

• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia 2
• There is frequently a lack of correlation between intensity of symptoms and seriousness of disease 2
• Women, elderly patients, and those with diabetes may present with atypical symptoms 2
• Chest tenderness on palpation or pain with inspiration markedly reduce the probability of ACS 1
• Troponin testing should rarely be requested to investigate patients with suspected ACS in the primary care setting - refer to hospital instead 4
• In primary care, an ECG is the only investigation required for most patients while referral is made to hospital 4

Initial Management

• For suspected ACS:

  • Administer aspirin (250-500 mg, chewable or water-soluble) 2
  • Consider short-acting nitrates if there is no bradycardia or hypotension 2
  • Monitor vital signs and cardiac rhythm continuously 2
  • Transport urgently to the ED, ideally by EMS, if in office setting 1
  • Avoid delayed transfer to the ED for troponin or other diagnostic testing 1

• For patients with STEMI or high-risk features, treat according to ACS guidelines with consideration for immediate reperfusion therapy 2

• For patients with non-cardiac causes of chest pain, treat according to the specific diagnosis 2