What is the appropriate management for a patient with chest pain after a fall?

Management of Chest Pain After a Fall

In patients ≥75 years of age presenting with chest pain after a fall, acute coronary syndrome (ACS) must be considered and ruled out first, as unexplained falls are a recognized atypical presentation of cardiac ischemia in older adults. 1

Immediate Assessment (Within 10 Minutes)

Obtain a 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes, regardless of the trauma history. 1, 2, 3

Critical Initial Steps:

• Draw cardiac biomarkers (troponin T or I, CK-MB) immediately on arrival and repeat at 10-12 hours after symptom onset. 1, 2, 3
• Assess hemodynamic stability: heart rate, blood pressure (systolic BP <100 or >200 mmHg indicates instability), respiratory status, and level of consciousness. 2, 3
• Perform focused cardiovascular examination to identify ACS complications (diaphoresis, tachypnea, crackles, S3 gallop, new murmur) or other life-threatening causes including aortic dissection (pulse differential, blood pressure differential between arms), pulmonary embolism (tachycardia, dyspnea), or cardiac tamponade. 1

Risk Stratification Based on Age and Presentation

Older patients (≥75 years) frequently present with atypical ACS symptoms, including unexplained falls, syncope, acute delirium, or isolated shortness of breath without classic chest pain. 1 The fall itself may have been precipitated by cardiac ischemia, arrhythmia, or syncope.

High-Risk Features Requiring Immediate Cardiac Workup:

• Ongoing chest discomfort or pressure 2
• Associated symptoms: diaphoresis, nausea, vomiting, dyspnea 2, 3
• ECG changes: ST-segment deviation, new Q waves, T-wave inversions 1, 2
• Hemodynamic instability 2, 3
• History of known ischemic heart disease 1

Immediate Interventions for Suspected ACS

If ACS cannot be excluded based on initial assessment:

• Administer aspirin 250-500 mg (chewable or water-soluble) immediately unless contraindicated. 1, 2, 3
• Provide sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses for ongoing ischemic discomfort, unless contraindicated by hypotension (systolic BP <90 mmHg) or bradycardia. 1, 2, 3
• Initiate low-molecular-weight heparin (preferably enoxaparin) for suspected ACS. 1, 2
• Administer supplemental oxygen if arterial saturation <90% or respiratory distress present. 1

Critical Pitfall: Do not use nitroglycerin response as a diagnostic test—relief with nitroglycerin does not distinguish cardiac from non-cardiac chest pain. 4

Disposition and Monitoring

If High-Risk Features Present:

Admit to coronary care unit or monitored bed with continuous ECG monitoring for patients with: 1, 2, 3

• Ongoing pain or ischemic ECG changes
• Positive troponin
• Hemodynamic abnormalities
• Left ventricular failure signs

If Initial Evaluation Negative but Intermediate Risk:

Observe in chest pain unit for 10-12 hours after symptom onset with: 1, 3

• Continuous cardiac rhythm monitoring
• ST-segment monitoring capability
• Resuscitation equipment immediately available
• Serial ECG and cardiac biomarkers

Perform stress testing or coronary CT angiography before discharge if serial biomarkers remain negative and no recurrent symptoms develop. 1, 5

Evaluation for Traumatic Chest Wall Injury

Only after ACS has been excluded should attention turn to potential traumatic causes of chest pain from the fall:

• Physical examination for chest wall tenderness, crepitus, ecchymosis, or deformity suggesting rib fractures or costochondral injury. 1
• Chest radiography is NOT routinely indicated for isolated chest wall pain without high-risk features (significant mechanism, anticoagulation, age >65, multiple injuries). 1
• CT chest may be considered if concern for occult rib fractures, pulmonary contusion, or other intrathoracic injury exists, but should not delay cardiac evaluation. 1

Management of Confirmed Musculoskeletal Chest Pain:

Once cardiac causes definitively excluded: 4

• First-line: Topical NSAIDs (with or without menthol gel) applied 3-4 times daily
• Second-line: Oral NSAIDs (ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily)
• Avoid opioids including tramadol due to risk of opioid use disorder outweighing benefits

Common Pitfalls to Avoid

• Do not assume the fall caused the chest pain—the chest pain (from cardiac ischemia) may have caused the fall. 1
• Do not dismiss mild pain as benign—symptom intensity does not correlate with disease severity in older adults. 4
• Do not delay transfer for troponin testing if evaluating in office setting—transport to ED immediately for suspected ACS. 1
• Women are at particular risk for underdiagnosis—always consider cardiac causes and obtain history emphasizing accompanying symptoms more common in women with ACS. 1

Follow-Up for Low-Risk Patients

If discharged after negative evaluation: 1

• Schedule outpatient follow-up within 72 hours with primary care physician
• Provide precautionary anti-ischemic medications (aspirin, sublingual nitroglycerin, beta-blockers)
• Give explicit instructions on seeking emergency care for recurrent or worsening symptoms