What are the guidelines for managing a patient presenting with chest pain?

Guidelines for Managing Chest Pain

Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1, as early identification or exclusion of life-threatening causes is critical for optimal outcomes. 1

Initial Assessment and Triage

• An initial assessment of chest pain is recommended to effectively triage patients based on the likelihood that symptoms may be attributable to myocardial ischemia 1
• A 12-lead ECG should be acquired and reviewed within 10 minutes of arrival to identify STEMI or other concerning ECG findings 2, 3
• High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction 1, 3
• Chest pain should be described as cardiac, possibly cardiac, or noncardiac rather than "atypical," as the latter term is misleading and can be misinterpreted as benign 1

Recognizing Chest Pain Presentations

• Chest pain means more than just pain in the chest - pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents 1
• Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome, though women may be more likely to present with accompanying symptoms such as nausea and shortness of breath 1
• In older patients (≥75 years), ACS should be considered when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, or when an unexplained fall has occurred 1

Risk Stratification

• For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols 1, 3
• Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease will benefit the most from cardiac imaging and testing 1, 3
• For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed 1

Initial Management

• Patients with suspected ACS should receive aspirin promptly - fast acting aspirin (chewable or water soluble) should be given as soon as possible 1, 4
• In patients with suspected ischemic chest pain, sublingual nitroglycerin may be administered if there is no bradycardia or hypotension 1, 3
• For pain relief in confirmed ACS, opiates may be considered, though be aware they can delay the absorption of oral antiplatelet agents like clopidogrel 1, 5

Diagnostic Pathways

• Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely 1
• The chest pain unit should be equipped to resuscitate patients and have appropriate monitoring equipment for cardiac rhythm, blood pressure, and blood oxygenation 1
• Continuous ST-segment monitoring with 12-lead ECG provides early diagnostic and prognostic information additional to standard three-lead continuous ECG monitoring 1

Shared Decision-Making

• Clinically stable patients presenting with chest pain should be included in decision-making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion 1
• Cultural competency training is recommended to help achieve the best outcomes in patients of diverse racial and ethnic backgrounds who present with chest pain 1

Common Pitfalls to Avoid

• Relying on nitroglycerin response is not necessarily diagnostic of myocardial ischemia 2
• Office-based troponin testing should not delay transfer to the ED in suspected ACS 2
• Describing chest pain as "atypical" can lead to underdiagnosis, especially in women and elderly patients 1
• Delayed ECG interpretation can delay critical interventions for conditions requiring immediate treatment 2

Differential Diagnosis Considerations

• Life-threatening causes of chest pain include ACS, aortic dissection, pulmonary embolism, pneumothorax, and esophageal rupture 1, 6
• Pericarditis typically presents with fever, pleuritic chest pain that worsens when supine, and pericardial friction rub 6
• Pneumothorax presents with dyspnea and pain on inspiration, unilateral absence of breath sounds 1, 6