What is the initial workup for in-patients presenting with chest pain?

Initial Workup for In-Patients with Chest Pain

For hospitalized patients presenting with chest pain, obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately, while simultaneously performing a focused cardiovascular examination to identify life-threatening causes including acute coronary syndrome, aortic dissection, pulmonary embolism, and esophageal rupture. 1, 2, 3

Immediate Actions (Within 10 Minutes)

ECG Acquisition and Interpretation

• Obtain and interpret a 12-lead ECG within 10 minutes of symptom recognition or presentation 1, 2, 3
• Look specifically for:
  • STEMI pattern: ST-segment elevation requiring immediate reperfusion therapy 1, 3
  • NSTE-ACS patterns: ST-segment depression or new T-wave inversions 1, 3
  • Posterior MI: Consider supplemental leads V7-V9 if clinical suspicion is high and initial ECG is nondiagnostic 1
  • Pericarditis: Diffuse ST elevation with PR depression 1, 2
  • New arrhythmias or conduction abnormalities 1

Cardiac Biomarkers

• Measure high-sensitivity cardiac troponin as soon as possible after presentation 1, 2, 3
• High-sensitivity troponins are the preferred standard for establishing myocardial injury 1

Focused History Elements

Pain Characteristics to Document

• Location and radiation: Retrosternal, left-sided, radiating to arm/neck/jaw suggests ACS; sudden tearing/ripping pain radiating to back suggests aortic dissection 2, 3
• Quality: Pressure, squeezing, gripping, heaviness, tightness, burning (high probability of ischemia); sharp, stabbing, fleeting, pleuritic (lower probability but does not exclude) 1, 2
• Temporal pattern: Gradual onset over minutes (ACS) versus sudden onset (dissection, PE) 2
• Duration: Persistent versus intermittent 1, 3
• Precipitating/relieving factors: Exertion, stress, position changes, breathing 2, 3

Associated Symptoms (Critical for Diagnosis)

• Dyspnea, diaphoresis, nausea: Classic ACS accompaniments 1, 2, 3
• Syncope or acute delirium: Especially in patients ≥75 years, strongly suggests ACS 1, 2
• Unexplained falls: In elderly patients, consider ACS 1, 2
• Fever: Suggests pericarditis, myocarditis, or pneumonia 1

Special Population Considerations

• Women: At risk for underdiagnosis; emphasize accompanying symptoms like nausea, fatigue, and dyspnea which are more common than in men 1, 2
• Elderly (≥75 years): May present with isolated dyspnea, syncope, delirium, or falls without classic chest pain 1, 2
• Diabetic patients: May have atypical presentations with pain in throat or abdomen 1

Focused Cardiovascular Examination

Life-Threatening Findings to Identify

• ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur (examination may be normal in uncomplicated cases) 1, 2, 3
• Aortic dissection: Pulse differential between extremities (30% of patients), blood pressure differential, aortic regurgitation murmur (40-75% in type A), widened mediastinum on chest X-ray 1
• Pulmonary embolism: Tachycardia and dyspnea in >90% of patients, pleuritic pain with inspiration 1, 2
• Esophageal rupture: Severe pain with abrupt onset, subcutaneous emphysema, unilateral decreased breath sounds 1
• Pericarditis: Fever, friction rub, pain worse supine and improved sitting forward 1, 2
• Pneumothorax: Unilateral absence of breath sounds, hyperresonant percussion 1, 2

Serial Monitoring

When Initial Workup is Nondiagnostic

• Perform serial ECGs when initial ECG is nondiagnostic, especially if clinical suspicion remains high, symptoms persist, or clinical condition deteriorates 1
• Repeat troponin measurements according to high-sensitivity troponin protocols (typically at 1-3 hours) 2, 3

Critical Pitfalls to Avoid

• Do not rely on nitroglycerin response as diagnostic for ACS, as esophageal spasm and other conditions may also respond 2, 3
• Do not assume reproducible chest wall tenderness excludes ACS: Approximately 7% of patients with reproducible pain still have ACS; ECG and troponin are mandatory 4
• Do not delay ECG or troponin testing based on atypical features or young age 2
• Do not use the term "atypical chest pain" as it is misleading; instead use "cardiac," "possibly cardiac," or "noncardiac" 1
• Do not assume young age excludes ACS: It can occur even in adolescents without traditional risk factors 2

Disposition Algorithm

• If STEMI or new LBBB: Immediate activation of catheterization lab per STEMI guidelines 1, 3
• If ST-depression or T-wave inversions: Treat according to NSTE-ACS guidelines 1, 3
• If nondiagnostic ECG with intermediate-to-high clinical suspicion: Continue serial ECGs and troponins, consider early cardiac imaging 1, 2
• If low-risk with negative initial workup: Clinical decision pathways should guide further management 1, 2