What initial workup and management should be ordered for a patient presenting with acute sharp chest pain in the emergency department?

Emergency Department Workup for Acute Sharp Chest Pain

For a patient presenting with sharp chest pain that began 30 minutes ago, obtain an ECG within 10 minutes of arrival, measure high-sensitivity cardiac troponin immediately, and perform a focused cardiovascular examination to identify life-threatening causes including acute coronary syndrome, aortic dissection, pulmonary embolism, pericarditis, and pneumothorax. 1, 2

Immediate Actions (Within 10 Minutes)

12-Lead ECG

• Must be obtained and interpreted within 10 minutes of arrival to identify STEMI, which requires immediate reperfusion therapy 1, 2
• Look for ST-segment elevation, ST-depression, new T-wave inversions, or new arrhythmias 1
• If initial ECG is nondiagnostic but clinical suspicion remains high, obtain serial ECGs 1
• Consider supplemental leads V7-V9 if posterior MI is suspected 1

Cardiac Troponin

• Measure high-sensitivity cardiac troponin (hs-cTn) as soon as possible after presentation 1, 2, 3
• This is the primary laboratory test for chest pain evaluation 3
• Serial measurements at 1-3 hours for high-sensitivity assays are needed to detect rising/falling patterns 3

Focused Physical Examination

• Perform immediately to identify life-threatening causes 1, 2
• Check vital signs including blood pressure in both arms (aortic dissection) 1
• Assess for diaphoresis, tachypnea, tachycardia, hypotension 1
• Auscultate for absent breath sounds (pneumothorax), friction rub (pericarditis), new murmurs (acute valvular disease) 1
• Palpate for chest wall tenderness (musculoskeletal) 1

Critical Differential Diagnosis for Sharp Chest Pain

Sharp chest pain characteristics make certain diagnoses more likely than acute coronary syndrome 1:

High Priority Life-Threatening Causes

• Pericarditis: Sharp, pleuritic pain worse when supine, relieved by sitting forward; look for friction rub and fever 1
• Aortic dissection: Sudden onset "ripping" or "tearing" pain radiating to back; check for pulse deficits and blood pressure differential between arms 1
• Pulmonary embolism: Sharp, pleuritic pain with dyspnea; assess for tachycardia, hypoxia 1
• Pneumothorax: Sharp pain with dyspnea on inspiration; unilateral absent breath sounds 1

Important Clinical Caveat

Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease 1. However, do not rely solely on pain character—complete the full workup as ACS can present atypically 1, 2.

Additional Essential Testing

Chest Radiograph

• Obtain to evaluate for pneumothorax, pneumonia, aortic dissection, and other pulmonary/thoracic causes 2, 3
• Particularly important given the sharp nature of the pain 1

Laboratory Tests Beyond Troponin

• Complete blood count, basic metabolic panel 1
• D-dimer if pulmonary embolism is suspected 4
• Inflammatory markers (CRP, ESR) if pericarditis is suspected 1

Immediate Management While Awaiting Results

Pain Relief

• Administer morphine intravenously titrated to pain severity before ECG interpretation is complete 1
• Pain itself causes sympathetic activation and increased blood pressure 1

Do NOT Use Nitroglycerin Response as Diagnostic

• Relief with nitroglycerin is not diagnostic of myocardial ischemia and should not be used as a diagnostic criterion 1, 2
• Nitroglycerin can relieve esophageal spasm and other non-cardiac causes 5

Aspirin Administration

• Give aspirin if ACS is suspected and no contraindications exist 1
• Can be administered while awaiting troponin results 1

Risk Stratification Based on Initial Results

If STEMI Present on ECG

• Activate immediate reperfusion therapy (PCI or thrombolysis) 1, 2
• Door-to-needle time for thrombolysis should be <30 minutes 1

If ST-Depression or T-Wave Inversions

• Treat according to NSTE-ACS guidelines 1, 2
• Consider antithrombotic therapy with heparin and antiplatelet agents 1

If ECG Nondiagnostic and Initial Troponin Negative

• Serial troponin at 3 hours (for high-sensitivity assays) 1, 3
• Continue monitoring with serial ECGs if symptoms persist 1
• Consider observation in chest pain unit for 10-12 hours from symptom onset 1

Common Pitfalls to Avoid

• Never delay transfer to ED for troponin testing in suspected ACS 1, 2, 3
• Do not discharge based on single troponin if symptom onset was <3 hours prior 1, 3
• Do not assume sharp pain excludes ACS—complete the full cardiac workup 1
• Check for contraindications before giving thrombolytics, including recent trauma, bleeding disorders, severe hypertension 1
• Establish IV access and continuous cardiac monitoring for all acute chest pain patients 1