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

Initial Management of Chest Pain

The initial management of chest pain must focus on rapid identification and treatment of life-threatening conditions—particularly acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism—through immediate ECG acquisition, cardiac monitoring, and early aspirin administration while simultaneously stabilizing hemodynamics. 1

Immediate Actions (Within 10 Minutes)

ECG and Monitoring

• Obtain a 12-lead ECG within 10 minutes of patient arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 1, 2
• Place the patient on continuous cardiac monitoring immediately with emergency resuscitation equipment and defibrillator readily available 1
• Monitor vital signs and cardiac rhythm continuously for all patients with suspected cardiac chest pain 1

Initial Stabilization

• Provide pain relief and correct hemodynamic instability without delay 3
• Administer supplemental oxygen if hypoxemic or in respiratory distress 1
• Establish intravenous access for medication administration 3

Early Pharmacotherapy

• Administer aspirin 250-500 mg (chewable or water-soluble) as soon as possible if ACS is suspected and no contraindications exist 1, 2
• Consider sublingual nitroglycerin for ongoing chest pain if no bradycardia or hypotension is present 1
• Important caveat: Relief with nitroglycerin should NOT be used as a diagnostic criterion for myocardial ischemia, as other conditions may show comparable response 1

History and Physical Examination

Critical Historical Elements to Assess

• Nature and quality of pain: crushing, pressure, tightness, sharp, or burning 1
• Onset and duration: sudden versus gradual, continuous versus intermittent 1
• Location and radiation: substernal, left-sided, radiating to jaw, neck, shoulders, or arms 1
• Precipitating and relieving factors: exertion, rest, position changes 1
• Associated symptoms indicating high-risk conditions: cold sweats, nausea, vomiting, syncope, dyspnea, or severe anxiety 1
• Interruption of normal activity is a key indicator of potentially serious pathology 1
• Cardiovascular risk factors: diabetes, hypertension, hyperlipidemia, smoking, family history 1

Physical Examination Priorities

• Assess for hemodynamic instability, signs of heart failure, or shock 3
• Note that physical examination contributes minimally to diagnosing myocardial infarction unless shock is present 1
• Evaluate for alternative causes: unequal blood pressures (aortic dissection), friction rub (pericarditis), asymmetric breath sounds (pneumothorax) 1

Laboratory and Diagnostic Testing

Cardiac Biomarkers

• Measure cardiac troponin (preferably high-sensitivity) as soon as possible after presentation for all patients with suspected ACS 1, 2
• Draw blood samples for CK-MB mass and troponin T or I on admission and at 10-12 hours after symptom onset 3
• Repeat troponin at 6-12 hours for risk stratification 2

Serial ECGs

• Perform serial ECGs if the initial tracing is nondiagnostic but clinical suspicion remains high, symptoms persist, or clinical condition deteriorates 1, 2
• Consider supplemental leads V7-V9 to rule out posterior myocardial infarction when initial ECG is nondiagnostic 1, 2

Imaging

• Obtain chest radiography to evaluate for alternative cardiac, pulmonary, or thoracic causes including pneumonia, pneumothorax, widened mediastinum, or heart failure 1, 2

Risk Stratification and Disposition

High-Risk Features Requiring Immediate Intervention

• Severe continuing pain with ischemic ECG changes 3
• Positive troponin test 3
• Left ventricular failure or hemodynamic instability 3
• Major arrhythmias 2
• Recurrent ischemia 2
• Diabetes mellitus in the setting of suspected ACS 2

Management Based on Risk

• If ST-segment elevation indicates evolving Q-wave infarction, initiate thrombolytic treatment within 30 minutes or activate catheterization laboratory for primary PCI 3
• Patients with high-risk features should be admitted to coronary care unit or intensive care with priority given to those at highest risk 3
• If acute coronary syndrome is suspected, low-molecular-weight heparin can be started in the emergency department 3
• Patients without high-risk features can be evaluated in a chest pain unit for 10-12 hours after symptom onset 3

Setting-Specific Considerations

Office or Outpatient Setting

• Patients with clinical evidence of ACS or life-threatening chest pain should be transported urgently to the emergency department, ideally by emergency medical services (EMS) rather than private vehicle 1, 4
• An ECG is the only investigation required in primary care while arranging transfer 4
• Never delay transfer for troponin or other diagnostic testing in the office setting 2
• Troponin testing should rarely be requested in primary care for suspected ACS 4

Critical Pitfalls to Avoid

• There is frequently a lack of correlation between intensity of symptoms and seriousness of disease—do not be falsely reassured by mild symptoms 1
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as dyspnea, nausea, vomiting, lightheadedness, or vague abdominal symptoms rather than classic chest pain 1
• Patients often delay seeking medical attention, with longer delays in older patients and those in rural areas 1
• The risk of discharging patients without correctly diagnosing ACS is substantial—without proper observation, 20-30% historically died or had MI within 4 weeks 3
• Only 10-15% of chest pain patients presenting to emergency departments have acute myocardial infarction, but missing this diagnosis has catastrophic consequences 3