What is the appropriate management for a patient with chest pain?

Management of Chest Pain

Obtain a 12-lead ECG within 10 minutes of patient arrival and immediately administer aspirin 160-325 mg (chewed) unless contraindicated, while simultaneously assessing for life-threatening conditions including acute coronary syndrome, aortic dissection, and pulmonary embolism. 1, 2

Immediate Assessment (First 10 Minutes)

Life-threatening differentials must be identified immediately:

• Acute Coronary Syndrome (ACS): Look for retrosternal chest discomfort building over minutes, with radiation to left arm/neck/jaw, accompanied by dyspnea, nausea, diaphoresis, or lightheadedness 1
• Acute Aortic Syndromes: Sudden-onset tearing or ripping pain with radiation to the back 1
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain, particularly in patients with risk factors 1

Mandatory initial actions within 5-10 minutes:

• Record and interpret 12-lead ECG to identify ST-segment elevation, depression, or T-wave changes 3, 1, 2
• Administer aspirin 160-325 mg (chewed, not swallowed) immediately unless contraindicated by known allergy or active GI bleeding 1, 2, 4
• Draw cardiac troponin (high-sensitivity preferred) and CK-MB mass on arrival 3, 2
• Assess vital signs for hemodynamic instability: heart rate <40 or >100/min, systolic BP <100 or >200 mmHg, cold extremities 2

Pain Management and Hemodynamic Support

Provide immediate symptom relief:

• Administer intravenous morphine titrated to pain severity, even before ECG interpretation, as pain relief reduces sympathetic activation and myocardial oxygen demand 2
• Give sublingual nitroglycerin only if systolic BP ≥90 mmHg and heart rate 50-100 bpm 2, 4
• Critical pitfall: Do NOT use nitroglycerin response as a diagnostic tool—esophageal spasm and other conditions also respond 1

Risk Stratification Based on ECG Findings

High-risk features requiring immediate coronary care unit admission:

• ST-segment elevation ≥1 mV in contiguous leads indicates thrombotic coronary occlusion requiring immediate reperfusion 1
• Severe continuing pain with ischemic ECG changes 3
• Positive troponin test (>99th percentile) 3, 2
• Left ventricular failure or hemodynamic abnormalities 3, 2

If STEMI identified on ECG:

• Door-to-needle time for thrombolysis must be <30 minutes, OR 3, 2
• First medical contact to balloon time <90 minutes (preferred; <120 minutes acceptable) 1
• Pre-hospital thrombolysis reduces mortality by 17%, saving 35 lives per 1000 when given within first hour versus 16 lives per 1000 when given 7-12 hours after symptom onset 1

If troponin elevated without ST-elevation (NSTEMI/Unstable Angina):

• Admit to coronary care unit with continuous cardiac monitoring 2
• Initiate dual antiplatelet therapy (aspirin plus P2Y12 inhibitor: clopidogrel, ticagrelor, or prasugrel) 1
• Start anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux 1

Serial Testing for Normal Initial ECG

If initial ECG is normal but clinical suspicion remains:

• Repeat troponin measurement at 10-12 hours after symptom onset 3, 2
• Serial ECGs if symptoms persist or recur 1
• Observe in chest pain unit for 10-12 hours after symptom onset 2
• Critical pitfall: The risk of discharging patients without correctly diagnosing ACS is high without proper observation—historically 20-30% either died or had MI within 4 weeks 3

Special Population Considerations

Women are at risk for underdiagnosis:

• Emphasize accompanying symptoms like nausea, fatigue, dyspnea, arm pain, jaw pain, and epigastric discomfort 1
• These atypical presentations are recognized symptoms of unstable angina or NSTEMI in women 1

Older adults (≥75 years):

• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1
• ACS must be considered even with atypical presentations 1

Young patients:

• Critical pitfall: Do NOT assume young age excludes ACS—it can occur in adolescents without risk factors 1
• Sharp, pleuritic pain does NOT exclude ACS, as pericarditis and atypical presentations can occur 1

Non-Cardiac Life-Threatening Causes

When ACS is excluded, evaluate for:

• Pulmonary embolism: Consider pulmonary scintigraphy or spiral CT examination 2
• Aortic dissection: Perform transthoracic/transesophageal echocardiography, CT, or MR imaging 2
• Pneumothorax and acute pericarditis: Though rare compared to ACS in Europe, these are life-threatening conditions requiring urgent intervention 3

Transport and Disposition Decisions

Call ambulance immediately for suspected ACS rather than attempting office-based evaluation:

• EMS transport allows for intervention if complications occur en route 1
• Pre-hospital ECG use reduces in-hospital delay time and mortality 1
• Critical pitfall: Do NOT delay transfer to ED for troponin testing in office settings when ACS is suspected 1

Chest Pain Unit Requirements

Facilities must be equipped with:

• Resuscitation capabilities and appropriate monitoring equipment for cardiac rhythm, blood pressure, and blood oxygenation 3, 2
• Continuous ST-segment monitoring with 12-lead ECG for early diagnostic and prognostic information 3
• Experienced physicians and nurses for careful diagnostic work-up and prompt treatment 3