What is the initial workup and management for a patient presenting with chest pain?

Initial Workup for Chest Pain

Obtain a 12-lead ECG within 10 minutes of presentation and measure cardiac troponin as soon as possible—these two tests form the foundation of acute chest pain evaluation and directly determine whether the patient requires immediate intervention for acute coronary syndrome. 1

Immediate Assessment (First 10 Minutes)

ECG Acquisition and Interpretation

• Perform 12-lead ECG within 10 minutes of patient arrival in any setting where chest pain suggests possible cardiac origin 1
• If ECG shows ST-segment elevation, new ST depression, or new left bundle branch block, immediately activate STEMI or NSTE-ACS protocols per established guidelines 1
• Consider supplemental leads V7-V9 in patients with intermediate-to-high ACS suspicion and nondiagnostic initial ECG to detect posterior MI (often "electrically silent" on standard 12-lead) 1
• Perform serial ECGs if initial tracing is nondiagnostic, especially when clinical suspicion remains high, symptoms persist, or clinical condition deteriorates 1

Critical History Elements

Focus on specific high-risk features rather than general history:

• Pain characteristics: Retrosternal pressure/heaviness building gradually over minutes, radiating to left arm/jaw/neck suggests ACS 2
• Associated symptoms: Diaphoresis, dyspnea, nausea, or syncope increase ACS likelihood 2
• High-risk presentations: Age >75 years with dyspnea/syncope/delirium, women with atypical symptoms, patients with diabetes/renal insufficiency 2
• Sudden "ripping/tearing" pain radiating to back with pulse differentials suggests aortic dissection 2
• Acute dyspnea with pleuritic pain and tachycardia (>90% of cases) suggests pulmonary embolism 2

Physical Examination Priorities

Target examination to identify life-threatening conditions:

• Pulse and blood pressure differentials between extremities (aortic dissection) 2
• New aortic regurgitation murmur (aortic dissection) 2
• Unilateral absence of breath sounds (tension pneumothorax) 2
• Friction rub with positional chest pain (pericarditis) 1, 2
• Costochondral joint tenderness reproducible with palpation (costochondritis) 1, 2

Laboratory Testing

Cardiac Troponin Measurement

• Measure cardiac troponin (preferably high-sensitivity troponin T or I) as soon as possible after presentation in all patients with suspected ACS 1
• Repeat troponin measurement at 6-12 hours after initial presentation for risk stratification 1
• Elevated troponin with rise/fall of ≥20% confirms myocardial infarction in appropriate clinical context 3
• Do not delay transfer to ED for troponin testing if patient initially evaluated in office setting with suspected ACS 1

Additional Laboratory Studies

• Hemoglobin to detect anemia as potential contributor 1

Imaging Studies

Chest Radiography

• Obtain chest X-ray to evaluate alternative cardiac, pulmonary, and thoracic causes (pneumonia, pneumothorax, widened mediastinum, heart failure) 1
• Should not delay urgent revascularization if indicated 1

Risk Stratification After Initial Testing

High-Risk Features Requiring Immediate Invasive Strategy

Patients with any of the following require urgent coronary angiography (ideally within hours, not days):

• Recurrent ischemia (recurrent chest pain or dynamic ST-segment changes, particularly ST depression or transient ST elevation) 1
• Elevated troponin levels 1
• Hemodynamic instability (hypotension, pulmonary rales) during observation 1
• Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
• Early post-infarction unstable angina 1
• Diabetes mellitus in context of ACS 1

Initial Medical Management for Non-ST Elevation ACS

While awaiting further evaluation, initiate:

• Aspirin 75-250 mg (or clopidogrel if aspirin contraindicated) 1
• Low molecular weight heparin or unfractionated heparin 1
• Beta-blocker (unless contraindicated) 1
• Nitrates (oral or IV) for persistent/recurrent chest pain 1
• GPIIb/IIIa inhibitor for high-risk patients proceeding to angiography 1

Setting-Specific Considerations

Office/Outpatient Setting

• If ECG unavailable, refer patient to ED immediately for ECG acquisition 1
• Transport patients with clinical evidence of ACS or life-threatening chest pain urgently to ED, ideally by EMS rather than private vehicle 1
• Never delay transfer for troponin or other diagnostic testing in office setting 1

Low-Risk Patients

For patients with twice-negative troponins (at presentation and 6-12 hours) and nondiagnostic ECGs:

• Consider stress testing or coronary CT angiography for further risk stratification 1
• Evaluate alternative diagnoses: costochondritis, GERD, anxiety/panic disorder 4

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as diagnostic criterion—esophageal spasm and other conditions also respond to nitroglycerin 2
• Do not dismiss atypical presentations in women, elderly patients, or those with diabetes—they frequently present without classic symptoms 2
• Do not rely on single normal ECG to exclude ACS—up to 6% of patients with evolving ACS have normal initial ECG 1
• Do not assume young age excludes serious pathology—consider pneumothorax, pulmonary embolism with risk factors, and congenital conditions 5