What is the management approach for a patient presenting with chest pain?

Management of Chest Pain

For any patient presenting with chest pain, immediately obtain a 12-lead ECG within 10 minutes of arrival, measure cardiac troponin as soon as possible, and administer aspirin 160-325 mg (chewed) unless contraindicated, while simultaneously assessing for life-threatening conditions including acute coronary syndrome, aortic dissection, and pulmonary embolism. 1, 2, 3

Immediate Actions (First 10 Minutes)

Triage and Initial Assessment

• Activate emergency medical services (EMS) for transport to the nearest emergency department if the patient calls from outside the hospital, particularly for severe or prolonged chest pain 1, 2
• Place patient on continuous cardiac monitoring with defibrillator readily available 1, 2
• Obtain vital signs immediately, looking specifically for hypotension (systolic BP <90 mmHg), tachycardia (HR >100 bpm), bradycardia (HR <50 bpm), tachypnea, or oxygen desaturation 2, 3
• Position patient in a seated or semi-recumbent position to minimize risk of hypotension-related falls 2, 4

Mandatory Diagnostic Tests

• Obtain and interpret 12-lead ECG within 10 minutes to identify ST-elevation myocardial infarction (STEMI), which requires immediate reperfusion therapy 1, 2, 3
• Draw cardiac troponin immediately upon presentation 1, 2, 3
• Obtain chest radiography to evaluate for pneumothorax, pneumonia, aortic dissection, or other pulmonary/thoracic causes 2

Immediate Pharmacologic Management

• Administer aspirin 160-325 mg (chewed, not swallowed) immediately unless contraindicated by known allergy or active gastrointestinal bleeding 1, 2, 3, 4
• Give sublingual nitroglycerin 0.4 mg if systolic BP ≥90 mmHg and heart rate is 50-100 bpm, repeating every 5 minutes up to 3 doses 2, 3, 4
• Administer supplemental oxygen only if oxygen saturation is low or patient is in respiratory distress 3
• Consider morphine intravenously for severe pain, titrated to effect 3

Critical History Elements to Obtain

Pain Characteristics

• Exact location and radiation pattern: retrosternal pain radiating to left arm, neck, or jaw suggests ACS; sudden tearing pain radiating to back suggests aortic dissection 2, 3
• Quality of pain: pressure, squeezing, or heaviness suggests cardiac origin; sharp, pleuritic pain suggests pulmonary embolism, pneumothorax, or pericarditis 2, 3
• Temporal features: gradual onset over minutes suggests ACS; sudden onset suggests aortic dissection or pulmonary embolism 2, 3
• Duration: prolonged pain (>20 minutes) increases likelihood of myocardial infarction 2, 3

Associated Symptoms

• Dyspnea, diaphoresis, nausea, vomiting, syncope, or lightheadedness all increase probability of ACS 2, 3
• Cold sweat, anxiety, or sense of impending doom are particularly concerning for acute MI 2

Risk Factors

• Age, diabetes mellitus, hypertension, hyperlipidemia, smoking, family history of premature coronary artery disease, and prior MI or revascularization 2, 3

Physical Examination Priorities

• Cardiovascular examination: assess for diaphoresis, new murmurs (suggesting papillary muscle rupture or ventricular septal defect), S3 gallop (heart failure), jugular venous distension, or signs of cardiogenic shock 2, 3
• Blood pressure in both arms: difference >20 mmHg suggests aortic dissection 2
• Pulmonary examination: crackles suggest heart failure or pneumonia; absent breath sounds suggest pneumothorax 2
• Note that physical examination contributes minimally to diagnosing MI unless shock is present 1, 3

Risk Stratification and Disposition

High-Risk Features Requiring Immediate Intervention

• STEMI on ECG: door-to-balloon time must be <90 minutes (or <120 minutes if acceptable) for primary PCI, or door-to-needle time <30 minutes for thrombolysis 3
• Hemodynamic instability, cardiogenic shock, or major arrhythmias 1
• Elevated troponin with ongoing ischemic symptoms 1
• Recurrent ischemia despite medical therapy 1

Intermediate-Risk Patients

• If initial ECG is nondiagnostic but clinical suspicion remains high, obtain serial ECGs every 15-30 minutes and consider supplemental leads V7-V9 to detect posterior MI 1, 2
• Serial troponin measurements at presentation and 3-6 hours later 1
• Admit to observation unit or hospital for serial evaluation 1

Low-Risk Patients

• For patients with normal ECG, negative initial troponin, and low clinical suspicion, consider structured observation protocol with repeat troponin at 3-6 hours 1
• If both troponins are negative and patient remains pain-free, consider provocative stress testing or cardiac imaging before discharge 1, 5
• Myocardial perfusion imaging has 100% sensitivity for MI and 97% negative predictive value for 1-year cardiac events when normal 5

Critical Pitfalls to Avoid

Diagnostic Errors

• Do not use nitroglycerin response as a diagnostic criterion for myocardial ischemia, as esophageal spasm and other conditions may respond similarly 1, 2, 3, 4
• Do not assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 3
• Do not dismiss sharp or pleuritic chest pain as non-cardiac, since pericarditis and atypical ACS presentations can occur 3
• Do not delay transfer to ED for troponin testing in office settings when ACS is suspected 3

Special Population Considerations

• Women may present with atypical symptoms including isolated nausea, fatigue, dyspnea, or vague discomfort without classic chest pain—maintain high index of suspicion 1, 3
• Elderly patients (≥75 years) frequently present atypically with isolated dyspnea, syncope, acute delirium, or unexplained falls without chest pain 3
• Diabetic patients may have silent ischemia or atypical presentations 1
• Address language barriers with formal translation services for non-English speaking patients to obtain accurate history 1

Treatment Contraindications

• Do not administer nitroglycerin if systolic BP <90 mmHg, heart rate <50 or >100 bpm, or if patient has taken phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) within 24-48 hours due to risk of severe hypotension 4
• Do not give nitroglycerin with guanylate cyclase stimulators (riociguat) 4
• Check for aspirin allergy or active gastrointestinal bleeding before administration 2, 3

Structured Protocols and Clinical Pathways

• Multidisciplinary, standardized protocols improve outcomes regardless of whether the institution is designated a "chest pain center"—the structured approach itself provides clinical and cost-effective benefit 1
• Use clinical decision algorithms incorporating ECG, cardiac biomarkers, serial monitoring, and risk stratification tools 1
• For low-risk patients, 6-hour observation protocols with repeat ECG, troponin, and stress testing can safely identify patients eligible for early discharge, reducing unnecessary admissions by up to 40% 1

Pre-Hospital and EMS Considerations

• Pre-hospital ECG acquisition reduces mortality and in-hospital delay time 3
• EMS personnel can administer aspirin, provide defibrillation, and manage complications en route 3
• Pre-hospital thrombolysis saves 23 lives per 1,000 patients when given within the first hour versus 16 lives per 1,000 when given 7-12 hours after symptom onset 3
• Patients with confirmed STEMI or cardiogenic shock should be transported directly to hospitals with interventional and surgical capability 1

Cost and Access Considerations

• Emergency Medical Treatment and Labor Act (EMTALA) requires emergency departments to provide stabilizing treatment regardless of ability to pay 3
• Many hospitals have financial assistance programs and charity care for emergency services 3
• The cost of delayed diagnosis of ACS far exceeds the cost of emergency evaluation 3