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

From the Guidelines

The workup for chest pain should begin with a thorough history and physical examination to determine the likelihood of life-threatening causes, and initial evaluation should include an electrocardiogram (ECG) to assess for acute coronary syndrome, along with cardiac biomarkers such as troponin levels 1.

Initial Evaluation

The initial assessment of patients presenting with acute chest pain is focused on the rapid identification of patients with immediately life-threatening conditions such that appropriate medical interventions can be initiated.

• Included among the potentially life-threatening (emergency) causes of chest pain are ACS, acute aortic syndromes, and PE 1.
• Vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature, should be measured.
• Additional tests may include a chest X-ray to evaluate for pulmonary causes, D-dimer for suspected pulmonary embolism, and point-of-care ultrasound if available.

Risk Stratification

For patients with suspected acute coronary syndrome, serial troponin measurements should be obtained (typically at 0,3, and 6 hours), and risk stratification tools like HEART, TIMI, or GRACE scores can guide management decisions 1.

• High-risk patients should receive aspirin 325mg immediately, along with consideration of other antiplatelet therapy and anticoagulation.
• Patients with ongoing ischemic symptoms may require nitroglycerin 0.4mg sublingually every 5 minutes for up to 3 doses, with careful blood pressure monitoring.
• Pain control with morphine 2-4mg IV may be appropriate for severe pain.

Noninvasive Imaging

Noninvasive imaging may be indicated for risk stratification and clinical management in both low-risk and intermediate-risk patients 1.

• The available noninvasive cardiac imaging modalities include chest radiographs, rest single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress SPECT MPI, echocardiography (transthoracic and transesophageal), multidetector CT, PET (metabolic and perfusion), and MRI.
• Noncoronary etiologies for chest pain can also be established with imaging, the results of which may alter the patient’s postdischarge care altogether.

From the Research

Initial Evaluation

• The initial evaluation of a patient presenting with chest pain should consider life-threatening causes such as aortic dissection, pulmonary embolism, pneumothorax, pneumomediastinum, pericarditis, and esophageal perforation 2
• Radiographic imaging should be performed in tandem with the initial clinical assessment and stabilization of the patient 2

Diagnostic Approach

• Evaluating patients with suspected acute coronary syndrome (ACS) in the emergency department involves obtaining a history, physical examination, electrocardiograms (ECGs), and cardiac troponin measurements in conjunction with risk calculators 3
• A formal ACS rule out testing, defined as serial three troponin testing, should be performed 4
• At least one troponin test and one ECG should be performed in most patients 4

Treatment and Management

• All patients with suspected ACS should receive aspirin, if not contraindicated, as soon as possible 3
• Those with an ST-segment elevation myocardial infarction (STEMI) or those without STEMI who are in unstable condition should be triaged to undergo reperfusion therapy, typically via percutaneous coronary intervention (PCI), within 120 minutes of first medical contact 3
• Patients also should receive nitroglycerin to relieve angina and beta blockers if not contraindicated 3
• For non-cardiac chest pain, a wide variation in diagnostic processes and treatment recommendations exists, reflecting the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely 4

Network and Collaboration

• The implementation of networks between hospitals (hub and spoke) with various levels of technology can provide optimal care while minimizing delays, thereby improving clinical outcomes 5
• Cardiologists should actively collaborate with all stakeholders, particularly emergency physicians, in establishing such networks 5