Is it appropriate to send a patient to the Emergency Room (ER) immediately if they are having chest pain without access to an immediate Electrocardiogram (EKG) in the clinic?

Immediate ER Transfer for Chest Pain Without Clinic EKG

Yes, if an EKG cannot be obtained in your clinic, the patient with chest pain should be referred immediately to the Emergency Department—and if acute coronary syndrome (ACS) or other life-threatening causes are suspected, transport should be via EMS, not personal vehicle. 1

The Critical Role of EKG Availability

The 2021 ACC/AHA Chest Pain Guidelines provide explicit Class 1 recommendations on this exact scenario:

• Unless a noncardiac cause is clearly evident, an ECG must be performed for patients with chest pain in the office setting 1
• If an ECG is unavailable in your clinic, the patient should be referred to the ED so one can be obtained 1
• The ECG must be acquired and interpreted within 10 minutes of arrival to any medical facility to identify STEMI and facilitate urgent reperfusion 1, 2

When to Call EMS vs. Sending to ER

Use EMS Transport (Not Personal Vehicle) If:

• Clinical evidence suggests ACS or other life-threatening causes (diaphoresis, hemodynamic instability, severe ongoing pain, dyspnea) 1, 2
• EMS provides critical advantages: prehospital ECG acquisition, trained personnel who can treat arrhythmias and chest pain en route, defibrillation capability, and shorter travel time 1
• Personal automobile transport is associated with increased risk and should be avoided 1

Direct ER Referral (Patient Can Drive/Be Driven) If:

• Stable chest pain without high-risk features but still requires ECG evaluation 1
• However, maintain a low threshold for EMS activation if any concerning features develop

The Harm of Delayed Transfer

The guidelines explicitly state (Class 3: Harm recommendation) that delayed transfer to the ED for troponin or other diagnostic testing beyond the ECG should be avoided 1, 2. This means:

• Do not attempt office-based troponin testing if it delays transfer 2, 3
• Do not wait for additional testing results before initiating transfer 1, 2
• Delayed transfer can be detrimental to outcomes, particularly if STEMI is present 1

Why This Matters for Outcomes

The evidence supporting immediate transfer centers on mortality and morbidity reduction:

• Early ECG recognition of STEMI improves outcomes by enabling timely reperfusion therapy 1, 2
• A substantial proportion of chest pain patients are transferred without prehospital ECG, resulting in avoidable delays in ED and reperfusion team readiness 1
• Up to 6% of patients with evolving ACS are discharged from the ED with a normal initial ECG, emphasizing that clinical assessment alone is insufficient 1, 3
• Initial clinical assessment by trained personnel has 100% sensitivity but only 54% specificity for ACS, meaning you cannot safely rule out ACS without objective testing 4

Common Pitfalls to Avoid

• Do not rely on symptom characteristics alone to determine if transfer is needed—even "atypical" presentations can be ACS, especially in women and elderly patients 3, 5
• Do not use nitroglycerin response as a diagnostic test—response to nitroglycerin does not reliably distinguish cardiac from noncardiac chest pain 2
• Do not assume stable vital signs mean low risk—patients can have normal vital signs and still have evolving ACS requiring serial ECGs and troponin monitoring 3
• Do not delay transfer waiting for "office hours" cardiology consultation—the 10-minute ECG window is critical 1, 2

The Bottom Line Algorithm

For any patient with chest pain in your clinic without EKG capability:

1. Assess for life-threatening features (severe pain, diaphoresis, hemodynamic instability, dyspnea) 1, 2
2. If present → Call EMS immediately 1, 2
3. If absent but noncardiac cause not evident → Refer to ED (patient may self-transport if truly stable) 1
4. Only discharge home if a clear noncardiac cause is identified 1

This approach prioritizes the mortality benefit of early STEMI recognition and the morbidity reduction from appropriate ACS management, which cannot be achieved without ECG evaluation 1, 2.