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 with chest pain should include immediate ECG within 10 minutes of arrival, cardiac troponin measurement, and continuous cardiac monitoring, with treatment guided by the suspected diagnosis. 1, 2

Immediate Assessment and Triage

• A 12-lead ECG should be obtained and interpreted within 10 minutes of patient arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 1
• Cardiac troponin should be measured as soon as possible for patients with suspected acute coronary syndrome (ACS) 2
• Patients should be placed on continuous cardiac monitoring with emergency resuscitation equipment nearby 2
• If the initial ECG is nondiagnostic but clinical suspicion for ACS remains high, serial ECGs should be performed to detect potential ischemic changes 1
• Supplemental ECG leads V7-V9 are reasonable to rule out posterior myocardial infarction when the initial ECG is nondiagnostic 1

History and Physical Examination Focus

• Assess pain characteristics including exact location, radiation, onset, duration, quality, severity, and aggravating/alleviating factors 2
• Evaluate for associated symptoms such as dyspnea, diaphoresis, nausea, vomiting, syncope, or anxiety 2
• Inquire about cardiovascular risk factors and past medical history 2
• Consider family history of cardiac disease or sudden death 3
• Note that physical examination contributes minimally to diagnosing heart attack unless there is associated shock 2

Initial Treatment Interventions

• For suspected ACS, administer fast-acting 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
• Withhold antithrombotic therapy if aortic dissection is suspected 1
• For patients with STEMI, follow STEMI guidelines with consideration for immediate reperfusion therapy 1
• For non-ST-elevation ACS, clopidogrel (300 mg loading dose followed by 75 mg once daily) plus aspirin (75-325 mg daily) has been shown to reduce cardiovascular events 4

Differential Diagnosis Considerations

• Cardiac causes: ACS (STEMI, NSTEMI, unstable angina), pericarditis, myocarditis 1, 2
• Vascular causes: aortic dissection, pulmonary embolism 1, 2
• Pulmonary causes: pneumothorax, pneumonia, pleuritis 1, 5
• Gastrointestinal causes: gastroesophageal reflux disease 6
• Musculoskeletal causes: chest wall pain, costochondritis 6
• Psychological causes: panic disorder or anxiety states 6

Risk Stratification

• High-risk features warranting immediate attention include recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus 2
• For suspected pulmonary embolism, use clinical prediction scores to determine the likelihood of diagnosis 1
• For aortic dissection, the ADD score can help identify high-risk patients who need urgent imaging 1

Transport and Referral Decisions

• Patients with suspected ACS or significant ECG changes should be transported immediately to the emergency department, ideally by emergency medical services (EMS) 1, 2
• Transfer of patients with severe symptoms or hemodynamic instability to intensive care units is recommended 1
• For suspected aortic dissection with ADD score ≥1, transfer to a center with 24/7 available aortic imaging and cardiac surgery is mandatory 1

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
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, or vague abdominal symptoms 2
• Always consider pericarditis in patients in whom fibrinolysis is considered for presumed STEMI 1
• Point-of-care D-dimer, troponin, and BNP tests are not recommended in the pre-hospital setting for suspected pulmonary embolism 1
• Lack of correlation between symptom intensity and disease seriousness is common 2

Specific Management Based on Diagnosis

• For STEMI: immediate reperfusion therapy according to guidelines 1
• For NSTE-ACS: antiplatelet therapy, anticoagulation, and risk stratification 1, 4
• For pulmonary embolism: anticoagulation and consideration of thrombolysis in hemodynamically unstable patients 1
• For aortic dissection: blood pressure control with beta-blockers as first-line therapy 1
• For pericarditis: anti-inflammatory medications and cardiology consultation 1