What is the appropriate management for a patient presenting with acute thoracic pain?

Management of Acute Thoracic Pain

Immediately obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin while simultaneously assessing for life-threatening conditions including acute coronary syndrome, aortic dissection, and pulmonary embolism. 1, 2

Immediate Life-Threatening Assessment

The first priority is rapid triage to identify conditions requiring urgent intervention. Severe, prolonged chest pain of acute onset mandates immediate hospital care regardless of the underlying cause. 1, 2

Critical High-Risk Features to Assess Immediately

For Acute Coronary Syndrome: 1, 3, 2

• Associated symptoms: Diaphoresis, nausea/vomiting, dyspnea, pallor, hemodynamic instability
• Pain characteristics: Radiation to arm/jaw, pressure or squeezing quality
• Vital signs: Hypotension, tachycardia, arrhythmias

For Aortic Dissection: 1

• High-risk pain features: Abrupt/instantaneous onset, severe intensity, ripping/tearing/stabbing quality
• High-risk examination findings: Pulse deficit, systolic blood pressure differential >20 mmHg between limbs, focal neurologic deficit, new murmur of aortic regurgitation
• High-risk conditions: Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, family history of aortic disease, known aortic valve disease, recent aortic manipulation, known thoracic aortic aneurysm

Immediate Diagnostic Actions

ECG (Within 10 Minutes)

Obtain and interpret a 12-lead ECG within 10 minutes of first medical contact. 1, 2 Look for:

• ST-segment elevation (STEMI requiring immediate reperfusion) 3, 2
• New left bundle branch block 4
• ST-segment depression or T-wave inversions (NSTEMI/unstable angina) 4
• Q waves 4

If initial ECG is nondiagnostic but suspicion remains high, obtain serial ECGs and consider supplemental leads V7-V9 to rule out posterior MI. 2

Cardiac Biomarkers

Measure high-sensitivity cardiac troponin immediately at presentation with results available within 60 minutes. 1

Use the 0h/1h algorithm: 1

• Obtain troponin at presentation (0 hours) and at 1 hour
• If both measurements are non-diagnostic and clinical suspicion persists, repeat at 3 hours 1
• For patients with symptom onset ≥3 hours before arrival and normal ECG, a single hs-cTn below the limit of detection can reasonably exclude myocardial injury 1

Continuous Monitoring

Place patient on continuous cardiac monitoring immediately with defibrillator readily available and establish IV access. 3, 2

Initial Interventions for Suspected ACS

Administer aspirin 250-500 mg (chewable or water-soluble) immediately unless contraindicated. 1, 2

Consider short-acting sublingual nitroglycerin ONLY if: 1, 2, 5

• No bradycardia or hypotension present
• Patient has not taken phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) 5
• Patient has not taken guanylate cyclase stimulators (riociguat) 5

CRITICAL PITFALL: Do NOT use nitroglycerin response as a diagnostic tool—relief does not confirm cardiac ischemia and other conditions may respond similarly. 6, 2

Risk Stratification

Low-Risk Patients (<1% 30-day risk of death or MACE)

Discharge home without admission or urgent cardiac testing is reasonable. 1

Intermediate-Risk Patients

Perform bedside transthoracic echocardiography to: 1, 7

• Establish baseline ventricular and valvular function
• Evaluate for wall motion abnormalities
• Assess for pericardial effusion
• Rule out other structural causes

Management in an observation unit is reasonable to shorten length of stay and lower costs. 1

High-Risk Patients

Immediate transfer to facility with cardiac catheterization capabilities if: 2

• STEMI on ECG
• Elevated troponin with ongoing symptoms
• Hemodynamic instability
• Major arrhythmias
• Recurrent ischemia

Differential Diagnosis Beyond ACS

Aortic Dissection

If high-risk features present, obtain immediate CT angiography of the chest. 1, 8, 9

D-dimer has 94% sensitivity but insufficient negative likelihood ratio in high-risk patients—cannot be used to rule out dissection in this group. 1

Question patients about: 1

• Connective tissue disorders (especially if <40 years old)
• Family history of aortic disease
• Recent aortic procedures

Pulmonary Embolism

CT angiography is the reference standard for diagnosis. 9

Other Considerations

Chest radiography is useful to evaluate for: 2

• Pneumothorax
• Pneumonia
• Pulmonary edema

Special Populations

Elderly patients, women, and those with diabetes may present with atypical symptoms: 3, 2

• Dyspnea as primary symptom
• Nausea/vomiting without chest pain
• Vague abdominal symptoms
• These presentations carry higher mortality risk and are associated with delayed diagnosis 3

Patients with baseline confusion require heightened reliance on objective findings (ECG, troponin, vital signs, physical exam) since history is unreliable. 3

Critical Pitfalls to Avoid

• Do not assume mild pain equals benign cause—symptom intensity does not correlate with disease severity. 6, 2
• Do not delay transport for office-based evaluation if ACS or other life-threatening condition suspected—call EMS immediately. 1, 2
• Do not use nitroglycerin response diagnostically. 6, 2
• Do not miss atypical presentations in high-risk groups (elderly, women, diabetics). 3, 2
• Do not forget to assess for pulse deficits and blood pressure differentials in all patients with acute chest pain. 1

Disposition

Patients with confirmed STEMI or high-risk NSTE-ACS require immediate reperfusion therapy (primary PCI preferred over thrombolytics when available within appropriate time window). 1

Patients with low-risk features and negative workup can be discharged with outpatient follow-up. 1

When in doubt about diagnosis after initial evaluation, admit for observation with serial troponins and provocative testing. 1