What is the appropriate management for a patient with aching, pressure-like, non-radiating chest pain, considering potential underlying conditions such as acute coronary syndrome (ACS) or gastroesophageal reflux disease (GERD)?

Management of Aching, Pressure-Like, Non-Radiating Chest Pain

Unless a non-cardiac cause is immediately evident, obtain a 12-lead ECG within 10 minutes and refer the patient to the emergency department for cardiac troponin measurement and definitive evaluation, as pressure-like chest pain is a classic presentation of acute coronary syndrome that requires urgent exclusion. 1

Immediate Assessment and Triage

Critical First Actions

• Obtain a 12-lead ECG within 10 minutes of presentation to identify ST-segment elevation myocardial infarction (STEMI), ST-segment depression, T-wave inversions, or other ischemic changes 1, 2
• If an ECG cannot be obtained in the office setting, immediately transfer the patient to the emergency department by emergency medical services (EMS) 1, 2
• Pressure-like chest pain is the most common presentation of non-ST-elevation acute coronary syndrome (NSTE-ACS), typically occurring at rest or with minimal exertion and lasting ≥10 minutes 1

High-Risk Features Requiring Immediate ED Transfer

Transport by EMS (not personal vehicle) if any of the following are present 1, 3:

• Continuing chest pain >20 minutes 1, 3
• Severe dyspnea 1
• Syncope or presyncope 1, 3
• Hemodynamic instability (hypotension, pulmonary rales, new murmurs) 1
• Diaphoresis, nausea, or vomiting accompanying chest pain 1

EMS transport is strongly preferred over personal vehicle because trained personnel can acquire a prehospital ECG, provide treatment for arrhythmias, implement defibrillation en route, and facilitate faster reperfusion if STEMI is identified 1, 2

Diagnostic Evaluation Algorithm

Step 1: ECG Interpretation (Within 10 Minutes)

• STEMI identified (persistent ST-elevation or new left bundle branch block): Immediate reperfusion therapy indicated—transfer urgently to catheterization lab or initiate fibrinolysis 1
• ST-depression or T-wave inversions: Consistent with NSTE-ACS—transfer to ED for troponin measurement and admission 1
• Normal or non-diagnostic ECG: Does NOT exclude ACS (occurs in 1-6% of ACS patients)—still requires ED evaluation with serial ECGs and troponin measurement 1, 2

Step 2: Cardiac Troponin Measurement

• Measure cardiac troponin as soon as possible after ED arrival (not in the office setting) 1, 2
• Troponin is the most sensitive test for diagnosing acute myocardial injury with >90% sensitivity and >95% specificity 2
• Critical pitfall: Delayed transfer to the hospital for troponin testing from the office setting can be detrimental and should be avoided 1, 4
• Repeat troponin measurement at 6-12 hours if initial value is normal but clinical suspicion remains high 1

Step 3: Risk Stratification

Use validated risk scores to guide management 5:

• HEART score (0-10): High-risk range (7-10) has LR 13 for ACS; low-risk range (0-3) has LR 0.20 5
• TIMI score (0-7): High-risk range (5-7) has LR 6.8 for ACS; low-risk range (0-1) has LR 0.31 5

Differential Diagnosis Considerations

Life-Threatening Cardiovascular Causes

Beyond ACS, consider 1, 6:

• Acute aortic dissection: Sudden tearing pain radiating to back, widened mediastinum on chest X-ray 1, 6
• Pulmonary embolism: Pleuritic pain with dyspnea and tachycardia in >90% of patients 1, 6
• Acute pericarditis: Sharp, pleuritic pain that worsens supine and improves sitting forward 1, 6

Non-Cardiac Causes (Consider Only After Cardiac Exclusion)

• Gastroesophageal reflux disease (GERD): Burning retrosternal discomfort, often meal-related 1, 7
• Esophageal spasm: Can mimic cardiac pain and may respond to nitroglycerin 1, 2
• Musculoskeletal causes: Costochondritis, cervical radiculopathy—typically reproducible with palpation 1
• Psychiatric disorders: Panic disorder, anxiety states—diagnosis of exclusion only 1, 8

Important caveat: Nitroglycerin response should NOT be used as a diagnostic tool, as esophageal spasm and other conditions may also respond 2

Initial Medical Management (If ACS Suspected)

In Office Setting (While Awaiting EMS)

• Aspirin 160-325 mg (chewed, not swallowed) immediately unless contraindicated by known allergy or active gastrointestinal bleeding 2, 3
• Sublingual nitroglycerin if systolic blood pressure >90 mmHg and heart rate 50-100 bpm 2, 3
• Oxygen only if oxygen saturation <90% 4

In Emergency Department

Once ACS is confirmed or highly suspected 1, 2:

• Continue aspirin therapy 1
• Add P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) 2
• Initiate anticoagulation with low-molecular-weight heparin or unfractionated heparin 1
• Consider glycoprotein IIb/IIIa inhibitor for high-risk patients undergoing early invasive strategy 1
• Intravenous morphine for pain relief (reduces sympathetic activation and myocardial oxygen demand) 2

Special Population Considerations

Women

• Higher risk of underdiagnosis as they frequently present with atypical symptoms including isolated dyspnea, nausea, fatigue, or epigastric discomfort without classic chest pain 2, 3
• Pressure-like chest pain in women should be taken seriously even without radiation 2

Older Adults (≥75 Years)

• May present with atypical symptoms such as isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1, 2
• Higher frequency of atypical presentations also seen in patients with diabetes mellitus, impaired renal function, and dementia 1

Patients with Diabetes

• Increased probability of NSTE-ACS and higher risk of atypical presentations 1
• Should have lower threshold for ED referral 1

Critical Pitfalls to Avoid

1. Never delay transfer for troponin testing in the office setting—this is associated with worse outcomes 1, 4
2. Do not assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 2
3. Do not rely on physical examination alone—it contributes almost nothing to diagnosing myocardial infarction unless shock is present 2
4. Do not use nitroglycerin response as a diagnostic test—esophageal disorders may also respond 2
5. Do not assume a normal initial ECG excludes ACS—serial ECGs are required if clinical suspicion remains high 1
6. Do not evaluate high-risk patients solely by telephone—facility-based evaluation with ECG and biomarkers is mandatory 3

Disposition Decision

Immediate ED Transfer by EMS

• Any high-risk features present 1, 3
• ECG shows ischemic changes 1
• Clinical suspicion of ACS remains high despite normal initial ECG 1, 2

Outpatient Evaluation May Be Considered

Only if ALL of the following are met 1, 8:

• Normal ECG 1
• No high-risk features 1
• Low-risk HEART score (0-3) or TIMI score (0-1) 5
• Clear non-cardiac cause identified (e.g., reproducible chest wall tenderness) 8

Even in low-risk patients, arrange prompt outpatient stress testing or coronary CT angiography within 72 hours 1, 8