What is the initial workup for a patient presenting with chest pain?

Initial Workup for Chest Pain

All patients presenting with chest pain require an ECG within 10 minutes of arrival and immediate assessment for life-threatening conditions including acute coronary syndrome, aortic dissection, pulmonary embolism, and esophageal rupture. 1, 2

Immediate Actions (First 10 Minutes)

ECG Acquisition

• Obtain and interpret a 12-lead ECG within 10 minutes of patient arrival in any setting (ED, office, or hospital) 1, 2
• Look specifically for ST-segment elevation (STEMI), new Q waves, ST-segment depression, new T-wave inversions, or new left bundle branch block 1, 2
• If initial ECG is nondiagnostic but clinical suspicion remains high, obtain serial ECGs, especially if symptoms persist or worsen 1
• Consider supplemental leads V7-V9 if posterior MI is suspected in patients with intermediate-to-high suspicion for ACS 1

Cardiac Biomarkers

• Measure cardiac troponin (cTn) as soon as possible after presentation in all patients with suspected ACS 1, 2
• Do not delay transfer to the ED from office settings to obtain troponin—this is harmful 1

Focused History

Pain Characteristics to Document

• Exact location and radiation pattern (retrosternal, left-sided, radiating to arm/neck/jaw suggests ischemia; tearing/ripping pain radiating to back suggests aortic dissection) 1, 2
• Quality of discomfort: pressure, squeezing, heaviness, tightness, burning, or gripping are high probability for ischemia; sharp, stabbing, fleeting, or pleuritic are lower probability 1, 2
• Onset and duration: gradual buildup over minutes suggests ACS; sudden onset suggests aortic dissection or PE 2
• Precipitating factors: exertion or stress-related pain increases likelihood of ischemia 1, 2
• Associated symptoms: dyspnea, diaphoresis, nausea, syncope, palpitations 1, 2

Cardiovascular Risk Factor Assessment

• Age, sex, diabetes, hypertension, hyperlipidemia, smoking history, and family history of premature CAD 2

Special Population Considerations

• Women: Emphasize accompanying symptoms (nausea, fatigue, dyspnea) as they are at risk for underdiagnosis of cardiac causes 1, 2
• Older adults (≥75 years): Consider ACS when presenting with atypical symptoms including isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1, 2
• Diabetic patients and elderly: May present with pain in throat or abdomen rather than chest 1

Focused Physical Examination

Cardiovascular Examination

• Assess vital signs: Look for diaphoresis, tachypnea, tachycardia, or hypotension suggesting ACS 1
• Cardiac auscultation: Listen for S3 gallop (suggests heart failure/ACS), new mitral regurgitation murmur (papillary muscle dysfunction), friction rub (pericarditis), or characteristic murmurs of aortic stenosis/regurgitation or hypertrophic cardiomyopathy 1
• Pulse examination: Check for pulse differentials between extremities (suggests aortic dissection—present in 30% of cases) 1
• Lung examination: Assess for crackles (pulmonary edema), unilateral decreased breath sounds (pneumothorax or PE), or signs of pneumonia 1

Additional Examination Findings by Diagnosis

• Chest wall tenderness: Reproducible pain with palpation suggests costochondritis 1, 3
• Abdominal examination: Epigastric tenderness (peptic ulcer disease), right upper quadrant tenderness with Murphy sign (gallbladder disease) 1

Setting-Specific Protocols

Office Setting

• If noncardiac cause is not evident, perform ECG immediately; if unavailable, refer patient to ED 1
• Transport urgently to ED by EMS (not private vehicle) if clinical evidence suggests ACS or other life-threatening causes 1, 2
• Never delay transfer for troponin or other diagnostic testing when ACS is suspected 1

Emergency Department

• All acute chest pain patients require ECG within 10 minutes and troponin measurement as soon as possible 1

Pre-hospital/EMS

• Patients or bystanders should activate 9-1-1 for acute chest pain to initiate transport by EMS rather than private vehicle 1, 2

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic tool for ACS—esophageal spasm and other conditions may also respond 2
• Do not assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 2, 4
• Do not describe chest pain as "atypical"—instead use "cardiac," "possibly cardiac," or "noncardiac" as these terms are more diagnostically specific 1
• Sharp or pleuritic pain does not exclude ACS—pericarditis and atypical presentations can occur 2
• Do not rely solely on physical examination to diagnose or exclude myocardial infarction—examination may be completely normal in uncomplicated cases 1, 2

Life-Threatening Differential Diagnoses to Consider

Acute Coronary Syndrome

• Retrosternal discomfort building gradually over minutes, often with radiation to left arm/neck/jaw, associated with dyspnea, nausea, diaphoresis 2

Aortic Dissection

• Sudden-onset tearing or ripping pain with radiation to back; look for pulse differential and 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, subcutaneous emphysema, history of emesis 1

Tension Pneumothorax

• Dyspnea and pain on inspiration, unilateral absence of breath sounds 1