What is the correct initial order of management for a patient presenting with chest pain?

Management Order for Chest Pain Presentation

For any patient presenting with chest pain, obtain an ECG within 10 minutes of arrival and assess for STEMI—this is the single most critical initial step that determines all subsequent management. 1

Immediate Initial Steps (First 10 Minutes)

1. ECG Acquisition and Interpretation

• Obtain and interpret a 12-lead ECG within 10 minutes of patient arrival to any medical facility 1, 2
• This is the pivotal decision point that triages patients to appropriate pathways 1
• If in an office setting without immediate ECG capability, transfer the patient to the ED by EMS immediately—do not delay 1

2. Simultaneous Vital Signs Assessment

• Assess hemodynamic stability: heart rate, blood pressure, respiratory rate, oxygen saturation 1, 2
• Look for high-risk features: heart rate <40 or >100/min, systolic BP <100 or >200 mmHg, cold extremities 2

3. Brief Focused History (While ECG is Being Obtained)

• Duration and character of pain (anginal symptoms: pressure, squeezing, heaviness in retrosternal location) 1
• Associated symptoms: diaphoresis, nausea, vomiting, dyspnea, radiation to neck/jaw/left arm 1
• Critical red flags: sudden ripping pain (aortic dissection), pain with inspiration (PE, pneumothorax), positional changes (pericarditis) 1

Management Based on ECG Findings

If STEMI Pattern (ST-Elevation or New LBBB)

1. Activate reperfusion protocol immediately 1, 2
2. Administer aspirin 250-500 mg (chewable or water-soluble) immediately 1, 2
3. Give sublingual or IV nitroglycerin (unless systolic BP <100 mmHg, heart rate <50 or >100 bpm, or right ventricular infarction suspected) 1, 2, 3
4. Provide IV morphine for pain relief (titrated to effect, typically 2-4 mg IV) 2
5. Initiate anticoagulation with enoxaparin or unfractionated heparin 2
6. Transfer to cardiac catheterization lab for primary PCI within 120 minutes (or administer fibrinolytic therapy if PCI unavailable) 1, 2

If Non-ST Elevation Pattern (ST-Depression, T-Wave Inversions, or Nonspecific Changes)

1. Draw cardiac troponin immediately (high-sensitivity troponin preferred) 1
2. Administer aspirin 250-500 mg 2
3. Give sublingual nitroglycerin (if not contraindicated) 2, 3
4. Initiate anticoagulation with enoxaparin 2
5. Obtain serial troponins (at presentation and 10-12 hours after symptom onset, or use rapid protocols with high-sensitivity troponin) 1, 2
6. Perform risk stratification using clinical features and troponin results to determine timing of invasive strategy 2

If Normal or Nondiagnostic ECG

1. Draw cardiac troponin immediately 1
2. Perform serial ECGs if symptoms persist or clinical suspicion remains high 1
3. Consider supplemental leads V7-V9 if posterior MI suspected 1
4. Obtain chest radiograph to evaluate for other cardiac, pulmonary, or thoracic causes 1
5. Repeat troponin testing per institutional protocol (typically at 3-6 hours with high-sensitivity assays) 1, 2

Critical Pitfalls to Avoid

• Never delay transfer to obtain troponin results in an office setting—this causes harmful delays in diagnosis and treatment 1, 4
• Never transport suspected ACS patients by personal automobile—always use EMS for trained personnel, defibrillation capability, and prehospital ECG 1
• Never rely on nitroglycerin response as diagnostic—relief with nitroglycerin does not confirm cardiac ischemia and can occur with esophageal spasm 1, 5
• Never use CK-MB or myoglobin when troponin is available—these are inferior biomarkers 1
• Never assume brief duration (<5 seconds) or very prolonged duration (>30 minutes constant) represents typical angina—these features suggest non-cardiac causes 5

Risk Stratification for Disposition

High-Risk Features Requiring CCU Admission

• Ongoing chest pain despite treatment 2
• Elevated troponin levels 2
• Hemodynamic instability or heart failure signs 2
• Recurrent ischemia or dynamic ECG changes 2
• Major arrhythmias 2

Low-to-Moderate Risk Management

• Observe in chest pain unit with continuous cardiac monitoring for 10-12 hours 2
• Perform stress testing or coronary CT angiography if serial troponins negative and ECG remains normal 1, 2

Special Considerations

Aortic Dissection Suspected (Sudden Ripping Pain, Pulse Differential)

• Control blood pressure and heart rate immediately (target HR <60 bpm, SBP 100-120 mmHg) 2
• Obtain CT angiography or transesophageal echocardiography urgently 2

Pulmonary Embolism Suspected (Dyspnea, Pleuritic Pain, Tachycardia)

• Assess clinical probability and obtain D-dimer if low-to-moderate probability 2
• Perform CT pulmonary angiography if indicated 2