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 for any patient with suspected cardiac chest pain, regardless of how "typical" or "atypical" the presentation appears. 1

Immediate Life-Threatening Differentials to Rule Out

Your primary goal is to rapidly identify or exclude these conditions within the first 10 minutes:

• Acute Coronary Syndrome (ACS): 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, with pulse differential between extremities (present in 30% of cases) 1, 2
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, tachycardia and dyspnea in >90% of patients 1, 2
• Esophageal Rupture: Severe pain with abrupt onset, subcutaneous emphysema, history of forceful emesis 1

Mandatory Initial Assessment Protocol

ECG Acquisition (Within 10 Minutes)

• Obtain and interpret 12-lead ECG within 10 minutes of patient arrival by a trained clinician 1, 2, 3
• Look for STEMI criteria, new left bundle branch block, ST-segment depression, T-wave inversions, or transient ST-elevation 1
• Critical pitfall: ST-segment depression in leads V1-V3 may indicate posterior STEMI—obtain posterior leads if suspected 1

Cardiac Biomarkers

• Measure cardiac troponin immediately, preferably high-sensitivity troponin (hs-cTn) 1, 2, 3
• Repeat timing: 1-2 hours for hs-cTn or 3-6 hours for conventional troponin if initial result is nondiagnostic 1
• Serial hs-cTn at 0 and 1-2 hours provides >99.5% negative predictive value when using validated clinical decision pathways 1

Focused Physical Examination

Perform a targeted cardiovascular exam looking for these specific findings 1:

• ACS: 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, widened mediastinum on chest X-ray, aortic regurgitation murmur (40-75% in type A) 1
• Pulmonary embolism: Tachycardia, dyspnea, accentuated P2, pain with inspiration 1
• Pericarditis: Fever, friction rub, pain worse supine and improved sitting forward 1
• Pneumothorax: Unilateral absent breath sounds, hyperresonance to percussion 1

Critical History Elements

Obtain these specific details systematically 2, 3:

• Pain characteristics: Exact location, radiation pattern (arm/jaw/neck/back), quality (pressure/tearing/sharp/burning), temporal features (sudden vs. gradual onset)
• Precipitating factors: Exertion, emotional stress, meals, deep breathing, positional changes
• Associated symptoms: Dyspnea, diaphoresis, nausea/vomiting, syncope, palpitations
• Cardiac risk factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking history, family history of premature coronary artery disease

Special Population Considerations

Women

• Women are at significant risk for underdiagnosis of ACS 1
• Emphasize accompanying symptoms more common in women: nausea, fatigue, dyspnea, jaw/back pain 1, 2

Older Adults (≥75 years)

• Consider ACS when atypical symptoms are present: isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1, 2

Diverse Populations

• Use formal translation services when English is not the primary language to obtain accurate history 1

Transport and Triage Decisions

Immediate EMS Transport (Call 9-1-1)

Activate 9-1-1 for EMS transport to the nearest ED if any of the following are present 1, 2:

• STEMI or new left bundle branch block on ECG
• ST-segment depression or T-wave inversions suggesting ischemia
• Hemodynamic instability (hypotension, shock)
• Suspected aortic dissection or pulmonary embolism
• Any clinical suspicion of ACS or life-threatening cause

Office Setting Management

• Do NOT delay transfer for troponin testing if ACS is suspected in an office setting 2, 4, 3
• Transport urgently to ED by EMS rather than obtaining office-based cardiac testing 2, 3

Common Pitfalls to Avoid

1. Reproducible chest wall tenderness does NOT rule out ACS: Approximately 7% of patients with reproducible pain still have ACS—you must still obtain ECG and troponin 4

2. Nitroglycerin response is NOT diagnostic: Esophageal spasm and other conditions may also respond to nitroglycerin 2, 3

3. Young age does NOT exclude ACS: ACS can occur even in adolescents without traditional risk factors 2

4. Sharp, pleuritic pain does NOT exclude cardiac causes: Pericarditis and atypical ACS presentations can present this way 2, 4

5. Normal initial troponin does NOT rule out ACS: Serial measurements are required—repeat at 1-2 hours for hs-cTn or 3-6 hours for conventional troponin 1

Alternative Diagnoses After Cardiac Causes Excluded

Only after obtaining ECG and troponin, consider these diagnoses 1, 4:

• Costochondritis/Tietze syndrome: Tenderness of costochondral joints on palpation
• GERD: Burning retrosternal pain, acid regurgitation, sour/bitter taste
• Pneumonia: Fever, localized pleuritic pain, egophony, dullness to percussion
• Anxiety/panic disorder: After thorough cardiac workup is negative

Additional Testing Based on Risk Stratification

For patients with negative initial ECG and troponin who remain at low-to-intermediate risk 1, 3:

• Exercise stress testing
• Coronary CT angiography
• Cardiac MRI
• Use evidence-based clinical decision pathways to guide appropriate resource utilization