From the Guidelines
The diagnostic workup for a patient presenting with chest pain should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG) and measurement of cardiac biomarkers (troponin) as soon as possible after presentation, 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 include:
- Vital signs
- Electrocardiogram (ECG) to be acquired and reviewed for ST-segment–elevation myocardial infarction (STEMI) within 10 minutes of arrival 1
- Cardiac biomarkers (troponin) to be measured as soon as possible after presentation 1
- Complete blood count
- Basic metabolic panel
- Chest X-ray
For suspected acute coronary syndrome, serial troponin measurements should be taken at 0,3, and 6 hours. Additional testing may include:
- Stress testing (exercise or pharmacologic)
- Coronary CT angiography
- Invasive coronary angiography based on risk stratification
The workup should be tailored to the patient's presentation, with attention to red flags such as radiation to arm/jaw, diaphoresis, dyspnea, or pain worsening with exertion, which suggest cardiac etiology. Other diagnostic tests to consider include:
- D-dimer for suspected pulmonary embolism (followed by CT pulmonary angiography if positive)
- CT aorta for suspected aortic dissection
- Esophageal studies for suspected gastrointestinal causes
According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline, patients with acute chest pain and suspected ACS initially evaluated in the office setting should not have delayed transfer to the ED for cTn or other diagnostic testing 1. The guideline also emphasizes the importance of early care for acute symptoms and sharing decision-making with clinically stable patients presenting with chest pain 1.
In patients with low-risk features, expedited outpatient evaluation within 72 hours may be appropriate, while those with intermediate to high risk of cardiac causes should be admitted for observation and further testing 1. Noninvasive imaging may be indicated for risk stratification and clinical management in both low-risk and intermediate-risk patients, and patient selection should be determined by clinical judgment and tools such as the HEART score 1.