What is the appropriate treatment for chest pain?

Treatment of Chest Pain

The appropriate treatment for chest pain depends entirely on immediate risk stratification: obtain a 12-lead ECG within 10 minutes of patient contact, measure cardiac troponin immediately, and initiate treatment based on whether the patient has STEMI, NSTE-ACS, or a noncardiac cause. 1, 2

Immediate Assessment and Life-Threatening Causes (First 10 Minutes)

All patients with chest pain require immediate identification of life-threatening conditions including acute coronary syndrome (ACS), acute aortic syndromes, and pulmonary embolism within the first 10 minutes. 2

• Obtain a 12-lead ECG within 10 minutes of arrival and interpret it immediately to identify STEMI, which requires urgent reperfusion therapy 1, 2
• Measure cardiac troponin as soon as possible when ACS is suspected 1, 2, 3
• Perform focused cardiovascular examination looking for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or new murmurs 2, 3
• Assess vital signs immediately including blood pressure, heart rate, respiratory rate, and oxygen saturation 2

Immediate Medical Management for Suspected ACS

For patients with suspected ACS, administer aspirin 160-325 mg orally immediately unless contraindicated (known allergy or active GI bleeding). 2, 3, 4

• Give sublingual nitroglycerin (one tablet dissolved under tongue) unless systolic blood pressure <90 mmHg or heart rate <50 or >100 bpm 2, 4

  • May repeat every 5 minutes up to 3 doses total over 15 minutes 4
  • Critical pitfall: Do NOT use nitroglycerin response as a diagnostic tool, as esophageal spasm and other conditions may also respond 2

• Administer morphine intravenously as the preferred analgesic, titrated to pain severity 2

• Provide supplemental oxygen if oxygen saturation is low 2

• Initiate continuous cardiac monitoring with defibrillator readily available 3

Treatment Based on ECG Findings

STEMI (ST-Elevation Myocardial Infarction)

For patients with STEMI identified on ECG, immediate reperfusion therapy is mandatory with door-to-needle time for thrombolysis <30 minutes OR first medical contact to balloon time <90 minutes (preferred). 2

• Activate emergency medical services (EMS) for immediate transport to a facility capable of primary percutaneous coronary intervention 1, 2
• Pre-hospital thrombolysis reduces mortality by 17%, with 23 lives saved per 1000 per hour of earlier treatment 2
• Thrombolytic therapy saves 35 lives per 1000 when given within first hour versus 16 lives per 1000 when given 7-12 hours after symptom onset 2

NSTE-ACS (Non-ST-Elevation Acute Coronary Syndrome)

For patients with new ischemic ECG changes or elevated troponin without ST-elevation, treat according to NSTE-ACS guidelines with aspirin, anticoagulation, and consideration for early invasive strategy. 1, 3

• Optimize guideline-directed medical therapy (GDMT) before additional cardiac testing in intermediate-risk patients with known CAD 1
• Perform serial troponin measurements at 6-12 hours from symptom onset, as a single measurement drawn less than 6 hours may miss myocardial injury 3
• Obtain serial ECGs every 15-30 minutes during the first hour if symptoms persist or recur 3

Risk-Stratified Testing and Management

Low-Risk Patients

For patients determined to be low risk after initial evaluation, urgent diagnostic testing for suspected coronary artery disease is not needed. 1

• Use clinical decision pathways for chest pain in the emergency department and outpatient settings routinely 1
• Discharge with outpatient follow-up once acute coronary syndrome is ruled out 5

Intermediate-Risk Patients Without Known CAD

For intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after negative or inconclusive evaluation for ACS, coronary computed tomography angiography (CCTA) is useful for exclusion of atherosclerotic plaque and obstructive CAD. 1

• Consider fractional flow reserve CT (FFR-CT) for coronary artery stenosis of 40-90% in proximal or middle segments to guide revascularization decisions 1
• Perform invasive coronary angiography (ICA) for moderate-severe ischemia on current or prior stress testing 1

Intermediate-Risk Patients With Known CAD

For intermediate-risk patients with acute chest pain who have known CAD and present with new onset or worsening symptoms, optimize guideline-directed medical therapy (GDMT) before additional cardiac testing. 1

• Perform ICA for worsening frequency of symptoms with significant left main, proximal LAD stenosis, or multivessel CAD on prior testing 1
• Consider stress imaging (PET/SPECT MPI, CMR, or stress echocardiography) for new onset or worsening symptoms 1

High-Risk Patients

For patients with acute chest pain designated as high risk (new ischemic ECG changes, troponin-confirmed acute myocardial injury, new-onset LV systolic dysfunction with EF <40%, newly diagnosed moderate-severe ischemia, hemodynamic instability, or high CDP risk score), invasive coronary angiography is recommended. 1

Critical Pitfalls to Avoid

• Never delay transfer to the ED for troponin testing in office settings when ACS is suspected—this worsens outcomes 2, 3
• Do not rely on a single normal ECG to exclude ACS when clinical suspicion remains high, as 30-40% of patients with acute MI present with normal or nondiagnostic initial ECGs 3
• Do not discharge patients based on a single troponin drawn less than 6 hours from symptom onset 3
• Do not assume young age excludes ACS—it can occur in adolescents without risk factors 2
• Transport by EMS, not personal automobile, for suspected ACS as personal transport is associated with increased risk 1, 2

Special Populations

Women

Women may be more likely to present with accompanying symptoms such as nausea, shortness of breath, and fatigue rather than classic chest pain, and are at risk for underdiagnosis of ACS. 1, 2

Older Adults (≥75 years)

Older adults may present with atypical symptoms like isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain—ACS should be considered in these cases. 2

Noncardiac Chest Pain

Once cardiac causes are excluded through appropriate testing, chest pain should be described as "noncardiac" rather than "atypical," as the latter term is misleading and can be misinterpreted as benign. 1

• Consider alternative diagnoses including pulmonary embolism, aortic dissection, pneumothorax, pneumonia, pericarditis, costochondritis, and gastrointestinal causes 2, 6, 7, 8
• Treat the underlying cause once identified through appropriate diagnostic workup 7, 8