What are the appropriate diagnostic steps and treatment options for a patient experiencing chest tightness, potentially with a history of cardiovascular disease or anxiety disorder?

Evaluation and Management of Chest Tightness

Any patient presenting with chest tightness requires immediate 12-lead ECG acquisition within 10 minutes and cardiac troponin measurement to identify life-threatening acute coronary syndrome, aortic dissection, or pulmonary embolism, regardless of whether anxiety or other non-cardiac causes are suspected. 1, 2

Immediate Life-Threatening Differentials to Rule Out

The priority is identifying conditions that cause morbidity and mortality:

• Acute Coronary Syndrome (ACS): Retrosternal pressure-type discomfort lasting ≥10 minutes, often radiating to left arm, neck, or jaw, with associated diaphoresis, dyspnea, or nausea 1, 2
• Acute Aortic Syndromes: Sudden-onset tearing or ripping pain with radiation to the back 1, 3
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, particularly in patients with risk factors 1, 3
• Tension Pneumothorax: Acute onset with respiratory compromise 3

Mandatory Initial Assessment Within 10 Minutes

Obtain a 12-lead ECG and interpret it within 10 minutes of patient contact—this is non-negotiable. 1, 2, 4

• ECG findings requiring immediate action: ST-segment elevation ≥1 mm in contiguous leads indicates STEMI requiring reperfusion within 90 minutes (PCI preferred) or 30 minutes (thrombolysis) 2, 4
• ST-depression, transient ST-elevation, or new T-wave inversion suggests NSTE-ACS 1
• Normal ECG does NOT exclude ACS—occurs in 1-6% of ACS patients and may miss left circumflex or right coronary occlusions 1
• If initial ECG is nondiagnostic but suspicion remains, repeat ECG at 15-30 minute intervals during the first hour 1

Measure cardiac troponin immediately upon presentation. 1, 2, 4

• High-sensitivity cardiac troponin has >90% sensitivity and >95% specificity for myocardial injury 2
• Elevation above 99th percentile indicates myocardial necrosis requiring coronary care unit admission 2

Critical History Elements

Focus on specific high-risk features rather than vague descriptions:

Pain characteristics that increase ACS probability:

• Prolonged ongoing rest pain (>10 minutes) 1
• Diffuse anterior chest wall discomfort (not localized/sharp) 1
• Radiation to left/right arm, neck, jaw, or back 1
• Precipitated by exertion or emotional stress 3

Associated symptoms indicating high risk:

• Diaphoresis, nausea, vomiting (autonomic activation) 1
• Dyspnea (most common angina equivalent) 1
• Syncope or presyncope 1

Risk factors requiring aggressive evaluation:

• Age >75 years, male sex, diabetes mellitus, renal insufficiency 1
• Prior MI, coronary revascularization, peripheral arterial disease 1
• Family history of premature CAD 2

Special Population Considerations

Women are at significant risk for underdiagnosis and require heightened vigilance: 2, 3

• More frequently present with jaw/neck pain, back pain, epigastric symptoms, nausea, and fatigue rather than classic chest pain 1, 2
• Use descriptors like "tearing" and "terrifying" more frequently 1
• Have higher rates of inappropriate ED discharge despite evolving MI 1

Elderly patients (≥75 years) often present atypically: 1, 2

• Isolated dyspnea, syncope, acute delirium, or unexplained falls without chest pain 2
• Age ≥75 is itself a major risk factor requiring full cardiac workup 2

Patients with diabetes, renal impairment, or dementia have increased frequency of atypical presentations 1

Immediate Medical Management

If ACS is suspected, initiate treatment immediately while diagnostic workup proceeds:

• Aspirin 160-325 mg chewed (not swallowed) unless contraindicated by active GI bleeding or known allergy 2, 4
• Sublingual nitroglycerin if systolic BP >90 mmHg and heart rate 50-100 bpm 2, 4
• Oxygen if hypoxemic 2
• Continuous cardiac monitoring with defibrillator readily available 4

Critical Pitfalls to Avoid

Do NOT use nitroglycerin response as a diagnostic tool—esophageal spasm, GERD, and other non-cardiac conditions also respond to nitroglycerin. 2, 4, 3

Do NOT assume young age excludes ACS—it can occur even in adolescents without traditional risk factors. 2

Do NOT dismiss sharp or pleuritic pain as non-cardiac—pericarditis and atypical ACS presentations can present this way. 2

Do NOT delay ED transfer for troponin testing in office settings—transport immediately by EMS if ACS suspected. 2, 4

Do NOT attribute symptoms to anxiety until comprehensive cardiac workup is negative—anxiety disorders are common in chest pain patients (15% have severe anxiety), but this does NOT exclude concurrent cardiac disease. 5, 6, 3

Differential Diagnosis for Non-Cardiac Causes

Only after ruling out life-threatening cardiac causes:

Gastrointestinal:

• GERD, esophageal spasm, peptic ulcer disease 1, 3

Musculoskeletal:

• Costochondritis (reproducible with palpation), chest wall pain 1, 3

Psychiatric:

• Anxiety disorders, panic attacks, somatoform disorders 1, 3
• Note: Anxiety is associated with coronary endothelial dysfunction in women with chest pain and non-obstructive CAD 5

Pulmonary (non-PE):

• Pneumonia, pleuritis, pneumothorax 1

Disposition Algorithm

If ST-elevation present: Immediate reperfusion—primary PCI (door-to-balloon <90 minutes preferred) or fibrinolysis (door-to-needle <30 minutes) 2, 4

If troponin elevated (>99th percentile) without ST-elevation: Admit to coronary care unit with continuous monitoring, initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation, and early invasive strategy 2

If ECG and initial troponin normal but intermediate-risk features present: Serial troponins, serial ECGs, observation with stress testing or coronary CT angiography before discharge 1

If low-risk with negative workup: Consider non-cardiac causes, but maintain low threshold for cardiac re-evaluation if symptoms recur 1

Additional Imaging When Indicated

• Chest X-ray: Identifies pulmonary causes, widened mediastinum in aortic dissection 1
• CT chest with contrast: Excludes pulmonary embolism and aortic dissection 1
• Transthoracic echocardiography: Detects regional wall motion abnormalities, pericardial effusion 1
• Coronary CT angiography: Cost-effective for low-risk patients, more rapid diagnosis than stress testing 1