Immediate Emergency Evaluation Required
This patient requires immediate emergency department evaluation by calling 9-1-1, as the combination of chest pain radiating below the chest with associated nausea represents potential acute coronary syndrome or other life-threatening conditions that demand urgent assessment within 10 minutes of arrival. 1
Life-Threatening Causes to Exclude Immediately
The presentation of chest pain with radiation and nausea mandates immediate consideration of:
Acute Coronary Syndrome (ACS): Nausea is a common accompanying symptom in both men and women with ACS, and women are particularly more likely to present with nausea alongside chest discomfort 1, 2. Upper abdominal pain (pain below the chest) is specifically recognized as an anginal equivalent symptom 1.
Myocardial Infarction: The combination of chest pain, upper abdominal discomfort, and nausea represents classic associated symptoms of cardiac ischemia 1. Common signs include diaphoresis, lightheadedness, and nausea or vomiting 1.
Aortic Dissection: While typically presenting with sudden "ripping" pain, this must be excluded given the severity of potential mortality 2, 3.
Pulmonary Embolism: Presents with acute dyspnea and chest pain, often with associated nausea 2, 3.
Esophageal Rupture: A life-threatening cause that can present with chest pain and upper abdominal symptoms 1, 3.
Immediate Actions Required
Call 9-1-1 immediately rather than attempting self-transport to a healthcare facility 1. The patient should:
Sit down immediately to prevent falls from potential lightheadedness or hypotension 4.
Obtain an ECG within 10 minutes of emergency department arrival to evaluate for ST-segment elevation myocardial infarction (STEMI) 1, 2.
Measure high-sensitivity cardiac troponin as soon as possible after presentation to establish or exclude myocardial injury 1, 2.
Consider aspirin administration while waiting for EMS: If signs and symptoms suggest heart attack and the patient has no aspirin allergy or recent bleeding, administer 1 adult 325-mg aspirin tablet (or 2-4 low-dose 81-mg tablets), chewed and swallowed 1.
Critical Physical Examination Findings
The emergency provider must immediately assess for:
Hemodynamic instability: Diaphoresis, tachypnea, tachycardia, hypotension, or signs of heart failure (crackles, S3 gallop) 1, 2.
Abdominal examination: The "hardness" described below the chest requires evaluation for epigastric tenderness, rigidity, or guarding that could indicate cardiac ischemia presenting as upper abdominal pain or other serious pathology 1.
Pulse differentials: Check for differences between extremities that might suggest aortic dissection 1, 2.
Risk Stratification Approach
Once life-threatening causes are being evaluated:
High-risk features requiring aggressive management include: prolonged rest pain (>20 minutes), recurrent ischemia during observation, elevated troponin, or hemodynamic instability 2, 5.
Structured risk assessment using evidence-based diagnostic protocols (GRACE 2.0 or TIMI risk scores) should guide further management 1, 2.
Common Pitfalls to Avoid
Do NOT assume noncardiac cause based on atypical features—upper abdominal pain and nausea are recognized anginal equivalents, particularly in women, elderly patients, and diabetics 1.
Do NOT delay transfer for troponin or other diagnostic testing if initially evaluated in an office setting—immediate ED transfer is mandatory 1.
Do NOT rely on nitroglycerin response as a diagnostic criterion for cardiac ischemia, as relief with nitroglycerin is not specific for myocardial ischemia 1.
Do NOT use the term "atypical" to describe this presentation—the guidelines explicitly discourage this misleading descriptor 1.