What is the best course of action for a female patient presenting with chest pain and hypertension (high blood pressure), with a blood pressure reading of 144/84 mmHg?

Management of Chest Pain with Elevated Blood Pressure (144/84 mmHg)

This patient requires immediate assessment for acute coronary syndrome and other life-threatening causes of chest pain, but does NOT meet criteria for hypertensive emergency and should not have aggressive blood pressure reduction. 1

Immediate Priorities

Assess for Life-Threatening Conditions

The presence of chest pain—regardless of the blood pressure reading—demands urgent evaluation for potentially fatal conditions 1:

• Acute coronary syndrome (ACS) - Obtain immediate ECG and high-sensitivity troponin 1
• Aortic dissection - Assess for radiation to back, pulse differentials, or severe tearing pain 1, 2
• Pulmonary embolism - Evaluate for dyspnea, risk factors, and hemodynamic instability 1
• Pneumothorax - Check for sudden onset dyspnea and unilateral breath sounds 1

Give aspirin 250-500 mg (chewable or water-soluble) immediately if ACS is suspected, unless contraindicated 1

Blood Pressure Classification

This blood pressure reading of 144/84 mmHg is Stage 1 hypertension but does NOT constitute a hypertensive emergency 2, 3:

• Hypertensive emergency requires BP >180/120 mmHg PLUS acute target organ damage 2, 4
• This patient's BP is well below the emergency threshold 2
• The rate of BP rise may be more important than the absolute value 2, 5

Diagnostic Workup

Essential Immediate Tests

• ECG - To detect ischemia, infarction, or arrhythmias 1
• High-sensitivity cardiac troponin - Preferred biomarker for myocardial injury 1
• Chest X-ray - To evaluate for pulmonary edema, pneumothorax, or other pulmonary pathology 1

Additional Laboratory Tests (if indicated)

• Complete blood count, basic metabolic panel, and renal function 1, 2
• D-dimer if pulmonary embolism is suspected 1
• BNP/NT-proBNP if heart failure is considered 1

Management Based on Chest Pain Etiology

If Acute Coronary Syndrome is Confirmed

• Activate emergency protocols immediately - Call for ambulance/transfer to cardiac catheterization facility 1
• Administer aspirin if not already given 1
• Give sublingual nitroglycerin - Only if no bradycardia or hypotension present 1
• Consider opiates for pain relief and anxiety reduction 1
• Do NOT aggressively lower blood pressure - The BP of 144/84 mmHg is appropriate for ACS management 1, 2

If Chest Pain is Non-Cardiac

Most chest pain in primary care is musculoskeletal (the most prevalent diagnosis), with cardiac causes accounting for only 10-34% of episodes 1:

• Pain affected by palpation, breathing, turning, twisting, or bending suggests non-cardiac origin 1
• Pain from multiple sites or well-localized chest wall tenderness indicates lower likelihood of angina 1
• Local tenderness on examination strongly suggests musculoskeletal cause 1

Blood Pressure Management

Current Visit Management

Do NOT treat this blood pressure acutely in the office setting 2, 3:

• BP of 144/84 mmHg requires confirmation with repeat measurements using validated device 3
• Acute pain or distress commonly causes transient BP elevation that normalizes when underlying condition is treated 2
• Aggressive acute BP lowering in this range may cause harm without benefit 1, 2

Outpatient Blood Pressure Management (After Chest Pain is Addressed)

If hypertension is confirmed on repeat visits, initiate pharmacological therapy as this represents Stage 1 hypertension 3, 6:

• For non-Black female patients: Start with low-dose ACE inhibitor or ARB (e.g., lisinopril 10 mg daily) 3, 6
• Target BP: <130/80 mmHg within 3 months 3, 6
• Lifestyle modifications: DASH diet, sodium restriction <1500 mg/day, weight management, regular physical activity 6
• Follow-up: Schedule within 2-4 weeks to assess response 3, 6

Critical Pitfalls to Avoid

• Do not dismiss chest pain based on "normal" or mildly elevated BP - Acute MI can occur at any BP level 1
• Do not aggressively lower BP in the acute setting without evidence of hypertensive emergency - This patient's BP does not meet emergency criteria 2, 4
• Do not use immediate-release nifedipine - Causes unpredictable precipitous BP drops 1, 2
• Do not delay cardiac workup to address blood pressure - Chest pain evaluation takes priority 1
• Do not assume musculoskeletal pain without proper cardiac evaluation - Women may present with atypical symptoms 1

Disposition

• If cardiac cause suspected or cannot be excluded: Refer to emergency department immediately 1
• If low-risk chest pain after evaluation: Can be managed outpatient with close follow-up and scheduled cardiac testing if indicated 1
• Address hypertension management: Schedule follow-up for BP management after acute chest pain is resolved 3, 6