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: retrosternal discomfort building over minutes, radiating to left arm/neck/jaw, with dyspnea, nausea, or diaphoresis 1
• Acute aortic syndromes: sudden-onset tearing/ripping pain with back radiation 1
• Pulmonary embolism: sudden dyspnea with pleuritic chest pain in patients with risk factors 1
• Pneumothorax and acute pericarditis, though less common 3

Mandatory initial actions within 5-10 minutes:

• Record and interpret 12-lead ECG 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 (HR <40 or >100/min, SBP <100 or >200 mmHg, cold extremities) 2

High-Risk Features Requiring Immediate CCU Admission

Patients with any of the following require immediate coronary care unit transfer: 3, 2

• Severe continuing pain or prolonged ongoing rest pain
• Ischemic ECG changes (ST-segment elevation ≥1 mV in contiguous leads, ST-depression, or T-wave inversions)
• Positive troponin test (>99th percentile)
• Left ventricular failure or hemodynamic abnormalities
• New murmurs, S3 gallop, or crackles on examination 1

Immediate Medical Management

Pain relief and stabilization must occur without delay: 3, 2

• Administer morphine IV titrated to pain severity—this reduces sympathetic activation and myocardial oxygen demand 2
• Give sublingual nitroglycerin (or IV) unless systolic BP <90 mmHg or HR <50 or >100 bpm 2, 4
• Provide oxygen if hypoxemic 1

Critical caveat: Do NOT rely on nitroglycerin response as a diagnostic tool—esophageal spasm and other conditions also respond to nitrates 1

Reperfusion Decision Algorithm for STEMI

If ST-segment elevation ≥1 mV in contiguous leads is present: 2

• Door-to-balloon time must be <90 minutes (preferred) or <120 minutes (acceptable) for primary PCI 1
• Door-to-needle time must be <30 minutes if thrombolysis is chosen 3, 2
• 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

Serial Biomarker Strategy

Repeat cardiac troponin at 10-12 hours after symptom onset if initial troponin is negative but clinical suspicion remains high 3, 2. Total CK alone is neither sensitive nor specific enough—high-sensitivity cardiac troponin is the preferred biomarker 1

Chest Pain Unit for Intermediate-Risk Patients

Patients without high-risk features but with concerning symptoms should be observed 10-12 hours: 3, 2, 5

• Continuous cardiac monitoring with arrhythmia alarms and ST-segment monitoring 3, 2
• Serial ECGs if initial ECG is nondiagnostic 1
• Equipment for resuscitation must be immediately available 2

This approach is safe, cost-effective, and prevents the 2-5% missed AMI rate that occurs when patients are inappropriately discharged 6

Special Population Considerations

Women are at high risk for underdiagnosis: 1

• Emphasize accompanying symptoms: nausea, fatigue, dyspnea, arm pain, jaw pain, epigastric discomfort
• Bilateral hand numbness may represent anginal equivalent symptoms 1

Older adults (≥75 years) may present atypically: 1

• Isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain
• Consider ACS even without typical chest pain presentation

Young patients: Sharp, pleuritic pain does NOT exclude ACS—pericarditis and atypical presentations occur, and ACS can occur even in adolescents without risk factors 1

Critical Pitfalls to Avoid

• Never delay ED transfer for troponin testing in office settings when ACS is suspected 1
• Do not assume normal ECG excludes serious pathology—pulmonary embolism, aortic dissection, and early ACS may have normal initial ECGs 3
• Avoid excessive nitroglycerin dosing—this may lead to tolerance development and severe hypotension, particularly in volume-depleted patients 4
• Do not discharge patients without 10-12 hour observation period if intermediate risk—the pre-aspirin/pre-heparin era mortality was 20-30% within 4 weeks for missed unstable angina 3

Transport Decisions

Call ambulance immediately for suspected ACS rather than attempting office-based evaluation—EMS transport allows intervention if complications occur en route and pre-hospital ECG reduces mortality 1