What are the initial steps in evaluating and managing a patient presenting with chest pain?

Initial Evaluation and Most Likely Differentials for Chest Pain

The most likely causes of chest pain vary dramatically by age and setting, but in emergency presentations, the immediate priority is rapid identification of life-threatening conditions—specifically acute coronary syndrome (ACS), acute aortic syndromes, and pulmonary embolism (PE)—which must be ruled out within the first 10 minutes through ECG acquisition. 1

Life-Threatening Differentials (Immediate Rule-Out Required)

Cardiovascular Causes

• Acute Coronary Syndrome (ACS): Retrosternal chest discomfort building gradually over minutes, often with radiation to left arm/neck/jaw, associated with dyspnea, nausea, diaphoresis, or lightheadedness 1
• Acute Aortic Syndromes: Sudden-onset tearing or ripping pain, often with radiation to the back 1
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, particularly in patients with risk factors 1

Other Emergency Causes

• Tension Pneumothorax: Sudden-onset sharp chest pain with dyspnea and respiratory distress 1, 2
• Esophageal Rupture: Severe chest pain following vomiting or instrumentation 1
• Pericarditis with Tamponade: Sharp chest pain worse with lying supine, improved by sitting forward 1

Common Non-Life-Threatening Differentials

By Age Group Distribution

The differential diagnosis shifts dramatically with age 1:

• Ages 18-44: Musculoskeletal causes (costochondritis) are most common, followed by anxiety/panic disorder and gastroesophageal reflux disease 1, 3
• Ages 45-64: ACS becomes increasingly common, along with musculoskeletal causes 1
• Ages ≥65: ACS is the leading serious cause, though musculoskeletal pain remains common 1

Specific Non-Emergency Causes

• Musculoskeletal (Costochondritis): Reproducible chest wall tenderness, sharp pain worsened by movement or palpation 4, 3
• Gastroesophageal Reflux Disease: Burning retrosternal pain related to meals, often relieved by antacids 4, 3
• Anxiety/Panic Disorder: Associated with hyperventilation, palpitations, and sense of impending doom 4, 3
• Pneumonia/Pleuritis: Pleuritic pain (sharp, worse with breathing), often with fever and cough 2, 3

Mandatory Initial Assessment (First 10 Minutes)

Immediate Actions

• Obtain 12-lead ECG within 10 minutes of arrival in any patient with suspected cardiac chest pain 1, 5, 6
• Measure cardiac troponin as soon as possible when ACS is suspected 1, 5, 6
• Perform focused cardiovascular examination looking for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or new murmurs 1, 5

Critical History Elements

Obtain these specific details, not just "comprehensive history" 1:

• Pain characteristics: Exact location, radiation pattern (left arm/jaw suggests cardiac), quality (pressure/squeezing vs sharp/stabbing) 1
• Temporal features: Onset (sudden vs gradual), duration (seconds vs minutes vs hours), pattern (constant vs intermittent) 1
• Precipitating factors: Exertion, stress, meals, breathing, position changes 1
• Associated symptoms: Dyspnea, diaphoresis, nausea, syncope, palpitations 1
• Risk factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD 1

Special Populations Requiring Extra Vigilance

Women: At risk for underdiagnosis; emphasize accompanying symptoms (nausea, fatigue, dyspnea) that are more common than classic chest pressure 1

Older adults (≥75 years): Consider ACS when presenting with atypical symptoms like isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1

Critical Pitfalls to Avoid

• Never rely on nitroglycerin response as diagnostic—esophageal spasm and other conditions also respond 1, 5
• Never delay transfer to ED for troponin testing in office settings when ACS is suspected 1, 5, 6
• Never assume young age excludes ACS—while rare in adolescents without risk factors, it must still be considered 4
• Sharp, pleuritic pain does NOT exclude ACS—pericarditis and atypical presentations occur 1

Disposition Algorithm Based on Initial Assessment

If ECG shows STEMI (ST elevation, new LBBB): Activate STEMI protocol immediately 5, 6

If ECG shows NSTE-ACS findings (ST depression, T-wave inversions): Treat per NSTE-ACS guidelines with urgent cardiology consultation 5, 6

If ECG nondiagnostic but high clinical suspicion: Obtain serial ECGs, repeat troponin at 6-12 hours, consider supplemental leads V7-V9 for posterior MI 6

If low suspicion for ACS and noncardiac cause evident: Consider outpatient workup with close follow-up, but only if ECG obtained and normal 1, 3