What is the recommended approach for a patient with intermittent chest pain, specifically regarding referral to a cardiovascular specialist and initial management?

Referral to Cardiovascular Specialist for Intermittent Chest Pain

Unless a clear noncardiac cause is evident, obtain an ECG immediately; if unavailable in your office, refer the patient to the emergency department for ECG acquisition within 10 minutes of arrival. 1

Immediate Triage Decision

High-Risk Features Requiring Emergency Department Transfer by EMS

Transport immediately to the ED by emergency medical services (EMS)—not by private vehicle—if any of the following are present: 1

• Clinical evidence of acute coronary syndrome (diaphoresis, tachypnea, tachycardia, hypotension) 1
• Severe pain with abrupt onset 1
• Hemodynamic instability 1
• New or worsening dyspnea 1
• Syncope or near-syncope 1

EMS transport is critical because it provides prehospital ECG acquisition, trained personnel for arrhythmia management and defibrillation en route, and shorter travel time to the ED. 1 Approximately 1 in 300 chest pain patients transported by private vehicle experiences cardiac arrest en route. 2

Office-Based ECG Interpretation

If you can obtain an ECG in your office: 1

• ST-segment elevation or new left bundle branch block: Activate STEMI protocol, arrange immediate EMS transport for primary PCI 1, 3
• ST-segment depression or T-wave inversions: Suspect NSTE-ACS, arrange immediate EMS transport 1, 2
• Normal or nondiagnostic ECG: This does not rule out acute coronary syndrome—up to 6% of patients with evolving ACS have normal initial ECGs 2

Critical pitfall: Never delay transfer to the ED for troponin or other diagnostic testing in the office setting—this is associated with worse outcomes. 1

Risk Stratification for Patients Without Immediate High-Risk Features

When Cardiovascular Referral is Indicated

Refer to cardiology for outpatient evaluation within 1-2 weeks if: 1, 2

• Recurrent chest pain with intermediate pretest probability of coronary artery disease 1
• Abnormal but non-acute ECG findings (left ventricular hypertrophy, bundle branch blocks, Q waves) 2
• Positive cardiac risk factors: diabetes, hypertension, hyperlipidemia, smoking, family history 1
• Age >40 years in men, >50 years in women with typical anginal symptoms 4, 5

When Expedited Outpatient Testing is Appropriate (Not Urgent Referral)

For low-risk patients with recurrent chest pain, arrange outpatient stress testing or coronary CT angiography rather than cardiology referral if: 1

• Previous coronary angiography within 5 years showing nonobstructive CAD (<50% stenosis) 1
• Previous coronary angiography within 5 years showing no occlusive CAD (0% stenosis) 1
• Previous coronary CT angiography within 2 years showing no coronary stenoses 1
• Normal stress test within the previous 12 months 1

In these cases, a single high-sensitivity troponin below validated threshold can reasonably exclude ACS within 30 days. 1

Specific Clinical Scenarios

Atypical or Noncardiac Features

If chest pain has the following characteristics, consider alternative diagnoses before cardiovascular referral: 1, 4

• Chest wall pain/costochondritis: Localized tenderness reproducible by palpation of costochondral joints 1, 4
• Gastroesophageal reflux disease: Burning retrosternal pain, acid regurgitation, sour/bitter taste 4
• Panic disorder/anxiety: Consider screening tools for depression and anxiety, as these affect healthcare utilization and return ED visits 1

Elderly and Diabetic Patients

Be aware that elderly patients and those with diabetes may present with atypical symptoms—maintain lower threshold for cardiovascular referral in these populations. 2

Follow-Up and Continuity of Care

For patients evaluated and discharged without acute findings: 1

• Notify the patient's primary physician of evaluation results 1
• Arrange follow-up within 72 hours 1
• Prescribe precautionary anti-ischemic treatment (aspirin, sublingual nitroglycerin, beta-blockers) while awaiting definitive testing 1
• Provide specific instructions on seeking emergency care if symptoms recur or worsen 1

Key Pitfalls to Avoid

• Never rely on pain severity alone to determine urgency—severity is a poor predictor of imminent complications such as cardiac arrest 3
• Never discharge based on a single normal ECG without further evaluation—consider serial troponin measurements 6-12 hours apart 3, 2
• Never transport high-risk patients by private vehicle—always use EMS 1, 2
• Never delay treatment while waiting for definitive diagnosis in patients with red flags 3