What is the diagnostic workup for acute chest pain?

From the Guidelines

The workup for acute chest pain begins with a thorough history and physical examination to determine the likely cause and severity, and should include vital signs, oxygen saturation, and an electrocardiogram (ECG) within 10 minutes of presentation to rapidly identify life-threatening conditions like myocardial infarction, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The initial assessment should focus on identifying patients with immediately life-threatening conditions, such as acute coronary syndrome, acute aortic syndromes, and pulmonary embolism.

• Key components of the initial assessment include:
  • Vital signs and oxygen saturation
  • Electrocardiogram (ECG) within 10 minutes of presentation
  • Laboratory tests, including cardiac biomarkers (troponin I or T, preferably high-sensitivity assays), complete blood count, basic metabolic panel, and coagulation studies
  • Chest X-ray to identify pulmonary causes, pneumothorax, or aortic abnormalities
• Additional imaging may be necessary, such as computed tomography (CT) angiography for suspected pulmonary embolism or aortic dissection, or coronary CT angiography for intermediate-risk patients, as outlined in the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1.
• For patients with concerning cardiac symptoms, serial troponin measurements (typically at 0,3, and 6 hours) are essential to rule out acute coronary syndrome, and stress testing (exercise or pharmacologic) may be appropriate for intermediate-risk patients with negative initial workup, as recommended by the ACR Appropriateness Criteria for acute nonspecific chest pain-low probability of coronary artery disease 1.
• Point-of-care ultrasound can rapidly assess for pericardial effusion, right ventricular strain, or wall motion abnormalities, and treatment should be initiated based on the suspected diagnosis, including oxygen for hypoxemia, aspirin (325mg) for suspected acute coronary syndrome, nitroglycerin (0.4mg sublingual) for angina, and appropriate pain management, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The use of high-sensitivity troponins is preferred for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely, and patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease will benefit the most from cardiac imaging and testing, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The evaluation of all patients should focus on the early identification or exclusion of life-threatening causes, and testing is not needed routinely for low-risk patients, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Throughout this process, it is essential to share decision-making with clinically stable patients presenting with chest pain, providing information about risk of adverse events, radiation exposure, costs, and alternative options to facilitate the discussion, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The use of structured risk assessment should be used for patients presenting with acute or stable chest pain, and the term "noncardiac" should be used if heart disease is not suspected, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The term "atypical" is a misleading descriptor of chest pain, and its use is discouraged, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome, and women may be more likely to present with accompanying symptoms such as nausea and shortness of breath, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Early care for acute symptoms is crucial, and patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The evaluation and diagnosis of chest pain should be based on the latest guidelines and evidence-based practice, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, and the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1, and the ACR Appropriateness Criteria for acute nonspecific chest pain-low probability of coronary artery disease 1.

From the Research

Diagnostic Workup for Acute Chest Pain

The diagnostic workup for acute chest pain typically involves a combination of clinical presentation, physical examination, electrocardiogram (ECG), and biochemical markers of myocardial damage.

• Clinical presentation: assessing the likelihood that signs and symptoms have a cardiac origin secondary to coronary artery disease 2
• Physical examination: to identify any signs of cardiac or non-cardiac causes of chest pain
• Electrocardiogram (ECG): to detect any changes in the heart's electrical activity that may indicate myocardial infarction or other cardiac conditions 3, 2
• Biochemical markers: such as high-sensitivity troponin (hs-troponin) assays, which are recommended for early rule-out protocols for acute myocardial infarction (AMI) 4, 3, 5, 6

Risk Stratification

Risk stratification is an important step in the management of acute chest pain, to identify patients who are at high risk of ischemic complications.

• Several scores have been derived from clinical trials to improve prediction of outcome 2
• Use of critical pathways can improve guideline adherence 2
• High-sensitivity cardiac troponin testing and classification of patients with myocardial injury based on pathogenesis, as recommended by the Universal Definition of Myocardial Infarction 6

Biomarkers for Myocardial Injury

Biomarkers such as cardiac troponin I (cTnI) and cardiac troponin T (cTnT) are considered the "gold standard" for diagnosing myocardial infarction.

• High-sensitivity troponin assays have been developed to enable precise quantification of extremely low troponin concentrations 4, 3, 5, 6
• These assays can detect myocardial injury more frequently and earlier, and can also rule out myocardial infarction with higher diagnostic accuracy 3, 6