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

Initial Workup and Management of Chest Pain

Obtain a 12-lead ECG within 10 minutes of patient arrival and measure cardiac troponin immediately—these two tests form the cornerstone of initial chest pain evaluation and determine whether the patient requires emergent cardiac intervention or can undergo further risk stratification. 1, 2, 3

Immediate Actions (First 10 Minutes)

ECG Acquisition and Interpretation

• Perform 12-lead ECG within 10 minutes of arrival in any setting where chest pain suggests possible cardiac origin 1, 2, 3
• Look specifically for ST-segment elevation, new ST depression, new left bundle branch block, or Q waves 2, 4
• If STEMI is identified, immediately activate reperfusion protocols 2, 3
• Obtain supplemental leads V7-V9 when initial ECG is nondiagnostic but suspicion remains intermediate-to-high, as these detect posterior MI 1, 3
• Repeat ECGs serially if initial tracing is nondiagnostic and symptoms persist or clinical condition changes 1, 3

Cardiac Monitoring and Vital Signs

• Place patient on continuous cardiac monitor with emergency resuscitation equipment and defibrillator readily available 2
• Monitor vital signs continuously for hemodynamic instability or arrhythmias 2

Laboratory Testing

• Measure cardiac troponin (preferably high-sensitivity) immediately upon presentation 1, 2, 3
• Repeat troponin at 6-12 hours after initial presentation for risk stratification 3
• Measure hemoglobin to detect anemia as a potential contributor 3

Focused History

Obtain specific characteristics that differentiate cardiac from non-cardiac causes 1, 2:

Pain Characteristics to Document

• Nature: Retrosternal discomfort described as pressure, heaviness, tightness, squeezing, or constriction suggests angina 1
• Onset and duration: Anginal symptoms build gradually over several minutes; sudden ripping pain suggests aortic dissection; fleeting seconds-long pain is unlikely ischemic 1
• Location and radiation: Characteristic radiation to left arm, neck, or jaw; pain localized to small area or radiating below umbilicus is unlikely cardiac 1
• Precipitating factors: Physical or emotional stress suggests stable angina; rest onset suggests ACS 1
• Associated symptoms: Cold sweat, nausea, vomiting, syncope, or anxiety/fear indicate potentially serious conditions 2

Red Flags Requiring Immediate Action

• "Worst chest pain of my life" with ripping quality, especially in hypertensive patients or those with known bicuspid aortic valve, suggests aortic dissection 1
• Sharp pain increasing with inspiration and lying supine suggests pericarditis, not ischemia 1
• Symptoms interrupting normal activity warrant urgent evaluation 2

Initial Imaging

• Obtain chest X-ray to evaluate for pneumonia, pneumothorax, widened mediastinum (aortic dissection), or heart failure 2, 3

Immediate Medical Management

For Suspected ACS

• Administer aspirin 250-500 mg (chewable or water-soluble) as soon as possible 2, 3
• Give short-acting nitrates if no bradycardia or hypotension present 2
• Initiate low molecular weight heparin or unfractionated heparin while awaiting further evaluation 3
• Start beta-blocker unless contraindicated 3
• Provide oxygen only if hypoxemic—routine oxygen is not indicated 2

Important caveat: Relief with nitroglycerin should NOT be used as a diagnostic criterion for myocardial ischemia, as other conditions may respond similarly 2

Risk Stratification and Disposition

High-Risk Features Requiring Urgent Coronary Angiography (Within Hours)

• Recurrent ischemia despite medical therapy 2, 3
• Elevated troponin levels 2, 3
• Hemodynamic instability 2, 3
• Major arrhythmias 2, 3
• Diabetes mellitus with ACS 2

Transport Considerations

• Transport by EMS, not private vehicle, for patients with clinical evidence of ACS or life-threatening chest pain 2, 3
• Never delay transfer for troponin results or additional testing in office settings 3
• If ECG unavailable in office, refer immediately to ED for ECG acquisition 3

Critical Pitfalls to Avoid

• Do not rely on symptom intensity to gauge severity—there is frequently poor correlation between symptom intensity and disease seriousness 2
• Recognize atypical presentations: Women, elderly patients, and diabetics may present with only dyspnea, nausea, vomiting, lightheadedness, or vague abdominal symptoms without classic chest pain 2
• Physical examination contributes minimally to diagnosing MI unless shock is present 2
• Do not order troponin in primary care to rule out ACS—this delays appropriate referral and provides false reassurance if negative on single measurement 5
• Chest pain represents a broad differential including life-threatening non-cardiac causes (pulmonary embolism, aortic dissection, tension pneumothorax, esophageal rupture) that require different management 1, 4