What are the guidelines for triaging chest pain in an urgent care setting?

Triaging Chest Pain in Urgent Care

In urgent care, immediately obtain a 12-lead ECG within 10 minutes of patient arrival and transfer any patient with suspected acute coronary syndrome (ACS) or other life-threatening conditions to the emergency department by EMS—do not delay transfer for troponin testing or additional workup in the office setting. 1

Immediate Actions (First 10 Minutes)

ECG Acquisition

• Obtain and interpret a 12-lead ECG within 10 minutes for any patient presenting with chest pain where a noncardiac cause is not immediately evident 1
• If an ECG cannot be obtained in your urgent care facility, immediately transfer the patient to the ED so one can be performed 1
• The 10-minute window is critical for identifying STEMI and initiating timely reperfusion therapy 1, 2

Identify Life-Threatening Conditions

Focus on the "big three" plus additional emergencies 2, 3:

• Acute Coronary Syndrome (ACS): Retrosternal discomfort building gradually over minutes, radiating to left arm/neck/jaw, with dyspnea, nausea, or diaphoresis 2
• Acute Aortic Syndromes: Sudden-onset tearing/ripping pain radiating to the back 2
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, especially with risk factors 2
• Tension pneumothorax, esophageal perforation, cardiac tamponade 3

Critical History Elements

Pain Characteristics That Matter

High probability descriptors for ischemia 1:

• Pressure, dull, squeezing, aching, gripping, burning, heaviness, tightness
• Exertional or stress-related
• Retrosternal location
• Central or left-sided radiation

Low probability descriptors 1:

• Stabbing, sharp, fleeting, shifting
• Right-sided or pleuritic
• Reproduced by palpation

Essential Questions

• Exact location and radiation pattern: Pain radiating to right arm (OR 2.23), both arms (OR 2.69), or central chest (OR 3.29) significantly increases AMI likelihood 4
• Temporal features: Gradual onset over minutes suggests ACS; sudden ripping pain suggests aortic dissection 1, 2
• Associated symptoms: Vomiting (OR 3.50), observed sweating (OR 5.18) strongly predict AMI 4
• Precipitating factors: Exertion, stress, meals, breathing, position changes 2
• Risk factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD 2

Physical Examination

Perform a focused cardiovascular examination to identify 1, 2:

• Diaphoresis, tachypnea, tachycardia, hypotension
• Crackles, S3 gallop, new murmurs
• Pulse differentials (aortic dissection)
• Unilateral absent breath sounds (pneumothorax)
• Pericardial friction rub (pericarditis)
• Costochondral tenderness (musculoskeletal)

Special Population Considerations

Women

• Women are at high risk for underdiagnosis of ACS 1, 2
• Emphasize accompanying symptoms more common in women: nausea, fatigue, dyspnea, arm pain, jaw pain, epigastric discomfort 1, 2
• Chest pain remains the dominant symptom in women with ACS, but accompanying symptoms may be more prominent 1

Older Adults (≥75 years)

• Consider ACS when atypical presentations occur 1, 2:
  • Isolated shortness of breath
  • Syncope or near-syncope
  • Acute delirium or confusion
  • Unexplained falls
• Classic chest pain may be absent 1

Transfer Decision Algorithm

IMMEDIATE EMS TRANSFER if any of the following 1:

1. ECG shows STEMI or ischemic changes (ST-elevation, ST-depression, new T-wave inversions)
2. Clinical evidence of ACS: Ongoing chest pain with high-risk features, hemodynamic instability, arrhythmias
3. Suspected aortic dissection, PE, or other life-threatening condition
4. ECG unavailable in your facility

Why EMS Transfer is Mandatory 1, 2:

• Allows prehospital ECG acquisition to facilitate reperfusion
• Trained personnel can provide treatment for chest pain, arrhythmias, and defibrillation en route
• Shorter travel time to ED
• Personal automobile transport is associated with increased risk and should be avoided 1

AVOID THIS CRITICAL ERROR 1:

Do NOT delay transfer to obtain troponin or perform additional diagnostic testing beyond the ECG in the urgent care setting when ACS is suspected—this delay can be detrimental to patient outcomes 1

If ECG is Nondiagnostic but Suspicion Remains

• Do not reassure and discharge based on a normal ECG alone 1, 2
• Transfer to ED for serial ECGs and troponin measurement 1
• High-sensitivity cardiac troponin is the most sensitive test for myocardial injury (sensitivity >90%, specificity >95%) and must be measured in the ED setting 2

Common Pitfalls to Avoid

1. Do not use nitroglycerin response as a diagnostic tool—esophageal spasm and other conditions may also respond 2
2. Do not assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 2
3. Do not dismiss sharp or pleuritic pain as non-cardiac—pericarditis and atypical ACS presentations can occur 2
4. Do not rely on "typical" vs "atypical" terminology—the term "atypical" is misleading and discouraged; use "noncardiac" if heart disease is not suspected 1
5. Do not assume rest pain or left arm radiation alone are diagnostic—these have limited diagnostic value (OR 0.67 and 1.36 respectively) 4

Low-Risk Patients Who May Be Managed Outpatient

Only after excluding life-threatening causes with ECG and clinical assessment 1, 2:

• Clear noncardiac etiology identified (e.g., costochondritis with reproducible tenderness, herpes zoster with dermatomal rash)
• Low-risk features by structured risk assessment
• Stable vital signs
• Normal or clearly noncardiac ECG

Use clinical decision pathways (HEART score, TIMI, GRACE) to systematically risk-stratify patients, though these are best applied in the ED setting with troponin availability 5