What is the appropriate initial evaluation and treatment for a patient presenting with chest pain?

Initial Evaluation and Treatment of Chest Pain

Obtain a 12-lead ECG within 10 minutes of patient arrival and measure cardiac troponin as soon as possible—these are mandatory first steps that should never be delayed, even if the pain seems reproducible or noncardiac. 1

Immediate Life-Threatening Assessment (First 10 Minutes)

Your primary goal is to identify or exclude life-threatening conditions immediately:

• Acute Coronary Syndrome (ACS): Look for retrosternal discomfort building over minutes, radiating to left arm/neck/jaw, with dyspnea, nausea, diaphoresis, or lightheadedness 2
• Acute Aortic Dissection: Sudden-onset tearing/ripping pain radiating to back, pulse differential between extremities (present in only 30% but highly specific), widened mediastinum on chest x-ray 1, 2
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, tachycardia and dyspnea present in >90% of patients 1, 2
• Esophageal Rupture: Severe pain with abrupt onset, emesis, subcutaneous emphysema, pneumothorax in 20% 1

Mandatory Initial Testing

ECG Interpretation (within 10 minutes): 1, 3

• STEMI: ST-segment elevation or new left bundle branch block → immediate reperfusion therapy
• NSTE-ACS: ST-segment depression, transient ST elevation, or T-wave inversions → urgent ACS protocol
• ST depression in V1-V3: Consider posterior STEMI and obtain posterior leads 1
• Widespread ST elevation with PR depression: Consider pericarditis 2, 4

Cardiac Troponin Measurement: 1, 3

• Use high-sensitivity troponin (hs-cTn) if available
• Repeat at 1-2 hours for hs-cTn or 3-6 hours for conventional troponin if initial value is nondiagnostic 1
• Changes within normal range but below 99th percentile can still signal cardiac ischemia 1

Focused Physical Examination

Perform a targeted cardiovascular exam looking for specific findings: 1

Emergency cardiac findings:

• Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur (examination may be completely normal in uncomplicated cases) 1

Aortic dissection:

• Pulse differential between extremities, signs of connective tissue disorders (Marfan syndrome features) 1

Valvular disease:

• Aortic stenosis: systolic murmur with delayed/diminished carotid pulse
• Aortic regurgitation: diastolic murmur, rapid carotid upstroke
• Hypertrophic cardiomyopathy: displaced left ventricular impulse, systolic murmur 1

Pericarditis:

• Fever, friction rub, pain worse when supine 1, 4

Critical History Elements

Obtain specific details about: 2, 3

• Pain characteristics: Exact location, radiation pattern, quality (pressure, sharp, burning), temporal features (sudden vs. gradual onset)
• Precipitating factors: Exertion, stress, meals, breathing, position changes
• Associated symptoms: Dyspnea, diaphoresis, nausea, syncope, palpitations
• Risk factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking, family history of premature coronary artery disease

Special Population Considerations

Women: 1

• At significant risk for underdiagnosis of ACS
• Emphasize accompanying symptoms more common in women: nausea, fatigue, dyspnea (not just classic chest pain)

Older adults (≥75 years): 1, 2

• May present with atypical symptoms: isolated dyspnea, syncope, acute delirium, or unexplained falls
• Maintain high suspicion for ACS even without classic chest pain

Diverse populations: 1

• Use formal translation services when English is not the primary language
• Cultural competency is essential to avoid unconscious biases that contribute to worse outcomes

Transport and Setting-Specific Decisions

If ACS is suspected: 1, 2, 3

• Activate 9-1-1 immediately for EMS transport to nearest emergency department
• Do NOT delay transfer for troponin testing in office settings
• EMS provides early assessment, prehospital ECG transmission, and intervention capability en route

If patient is stable with low suspicion: 5, 6

• Consider exercise stress testing, coronary CT angiography, or cardiac MRI for intermediate-risk patients
• Use evidence-based clinical decision pathways to reduce unnecessary testing while maintaining high negative predictive value

Critical Pitfalls to Avoid

Do not rely on these to rule out ACS: 2, 4, 3

• Nitroglycerin response (esophageal spasm also responds)
• Reproducible chest wall tenderness (7% of patients with reproducible pain still have ACS, though negative predictive value is 98.1%) 4
• Young age (ACS can occur even in adolescents)
• Sharp or pleuritic quality (pericarditis and atypical presentations occur)

Do not delay critical actions: 1, 3

• Never delay ECG beyond 10 minutes
• Never delay transfer to ED for office-based troponin testing
• Never delay reperfusion therapy for additional diagnostic testing in STEMI

Alternative Diagnoses After Cardiac Exclusion

Once ACS is ruled out with negative ECG and troponins, consider: 1, 4, 5, 6

• Costochondritis: Tenderness of costochondral joints on palpation
• GERD: Burning retrosternal pain, acid regurgitation, sour/bitter taste
• Pneumonia: Fever, localized pleuritic pain, dullness to percussion, egophony
• Pneumothorax: Unilateral absent breath sounds, hyperresonant percussion
• Panic disorder: Associated anxiety symptoms, but remains a diagnosis of exclusion