Yes, Absolutely Send the Patient to the ER Immediately
If you cannot obtain an EKG in your clinic for a patient with chest pain, you must send them to the Emergency Department urgently, ideally by EMS rather than personal vehicle. 1
Critical Guideline Requirements
The 2021 ACC/AHA Chest Pain Guidelines are unequivocal on this matter:
An ECG should be performed for all patients with chest pain in the office setting unless a noncardiac cause is evident; if an ECG is unavailable, the patient must be referred to the ED so one can be obtained. 1
Patients with clinical evidence of acute coronary syndrome (ACS) or other life-threatening causes should be transported urgently to the ED by EMS, not by personal automobile. 1
Delayed transfer to the ED for troponin or other diagnostic testing should be avoided—this is classified as a Class 3: Harm recommendation. 1
Why EMS Transport is Preferred
When transferring from an office setting, EMS provides critical advantages over personal vehicle transport: 1
- Acquisition of a prehospital ECG, which facilitates rapid reperfusion if STEMI is present
- Trained personnel who can treat chest pain, manage arrhythmias, and perform defibrillation en route
- Shorter travel time to the ED with traffic priority 1
Personal automobile transport for suspected cardiac chest pain is associated with increased risk and should be avoided. 1
The 10-Minute ECG Rule
Regardless of setting, an ECG must be acquired and reviewed for STEMI within 10 minutes of arrival to any medical facility. 1, 2 If this cannot be achieved in your office, immediate transfer to the ED is mandatory. 1 A substantial proportion of patients are transferred without prehospital ECG, resulting in avoidable delays in reperfusion therapy. 1
Why You Cannot Wait for Additional Testing
Never delay transfer to obtain troponin levels or other diagnostic tests in the office setting. 1, 2 The guidelines explicitly state this causes harm. 1 Cardiac troponin should be measured as soon as possible after ED presentation, not in the office. 1, 2
The Risk of Missing Life-Threatening Diagnoses
Without an ECG, you cannot exclude: 3, 2, 4
- STEMI requiring immediate reperfusion
- NSTE-ACS with ST depression or T-wave inversions
- Pericarditis with diffuse ST elevation and PR depression
- Pulmonary embolism
- Aortic dissection
- Pneumothorax
Even patients with normal initial ECGs have a 1.3% risk of myocardial infarction, 5 and those with nonspecific ECG changes have a 14.6% MI risk. 5 You cannot stratify this risk without the ECG.
Common Pitfalls to Avoid
Never assume reproducible chest wall tenderness excludes serious pathology—7% of patients with palpable tenderness have ACS. 4
Do not rely on nitroglycerin response as diagnostic—relief with nitroglycerin neither confirms nor excludes myocardial ischemia. 2, 4
Do not underestimate risk in women or elderly patients—women are at risk for underdiagnosis of ACS, and patients ≥75 years may present with atypical symptoms like syncope, delirium, or unexplained falls. 3, 4
Special Considerations for Low-Risk Patients
Even if you clinically assess the patient as low-risk, you cannot safely discharge them without objective testing. 1 While research shows that immediate exercise testing can be safe for truly low-risk patients in the ED setting, 1, 6 this requires first ruling out acute MI with ECG and troponin. 1, 7 Without an ECG in your clinic, you cannot determine if the patient is truly low-risk. 5