What is the immediate evaluation and management approach for a patient presenting with shortness of breath and chest pain in a primary care office?

Immediate Management of Chest Pain and Shortness of Breath in Primary Care

If a noncardiac cause is not immediately evident, obtain a 12-lead ECG within 10 minutes; if an ECG is unavailable in your office, immediately refer the patient to the emergency department by EMS—do not delay transfer for troponin testing or additional diagnostics, as this causes harm. 1, 2

Critical First Actions (Within 10 Minutes)

Obtain ECG Immediately

• Acquire and interpret a 12-lead ECG within 10 minutes of patient arrival to identify STEMI, ischemic changes, or other life-threatening conditions 1, 3
• If your office lacks ECG capability, immediately arrange EMS transport to the ED—do not have the patient drive themselves 1, 2
• Review the ECG for ST-segment elevation (STEMI), ST-segment depression, T-wave inversions, or PR depression (pericarditis) 1, 3

Perform Focused Cardiovascular Examination

• Assess for signs of hemodynamic instability: diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new murmurs 1, 3
• Check blood pressure in both arms if aortic dissection is suspected (>20 mmHg difference suggests dissection) 1
• Auscultate for pericardial friction rub (scratching sound at left sternal border suggests pericarditis) 4

Obtain Targeted History

Pain Characteristics That Suggest ACS

• High-probability descriptors: Central, pressure, squeezing, heaviness, tightness, exertional, retrosternal, radiating to left arm/neck/jaw 1
• Low-probability descriptors: Sharp, stabbing, fleeting (seconds), pleuritic, right-sided, reproducible with palpation 1
• Temporal pattern: Anginal symptoms build gradually over minutes; sudden "ripping" pain suggests aortic dissection 1

Associated Symptoms

• ACS indicators: Dyspnea, nausea, diaphoresis, lightheadedness, left arm tingling 1, 3
• In patients ≥75 years: Consider ACS even with atypical presentations like isolated dyspnea, syncope, acute delirium, or unexplained falls 1
• In women: Emphasize accompanying symptoms like arm pain, jaw pain, epigastric discomfort, nausea, fatigue—women are at risk for underdiagnosis 1, 2

Risk Factors

• Document age, diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD, prior MI or revascularization 1, 3

Immediate Decision Algorithm

If Clinical Evidence of ACS or Life-Threatening Cause

Transport urgently to ED by EMS, not by personal vehicle 1, 2

Life-threatening conditions to identify:

• Acute coronary syndrome: Retrosternal discomfort with radiation, dyspnea, diaphoresis 1, 3
• Aortic dissection: Sudden tearing/ripping pain radiating to back, blood pressure differential between arms 1, 3
• Pulmonary embolism: Sudden dyspnea with pleuritic chest pain, risk factors for thromboembolism 3, 5
• Tension pneumothorax: Sudden dyspnea, absent breath sounds, tracheal deviation 3

If ECG Shows STEMI

• Call 911 immediately for EMS transport 1, 2
• Administer aspirin 162-325 mg (chewed) unless contraindicated 3
• Do not delay transport for any additional testing in the office 1, 2

If ECG is Normal or Shows Nonspecific Changes

• Still refer to ED if clinical suspicion for ACS remains—troponin must be measured as soon as possible after ED presentation, not in the office 1, 2
• Delaying transfer for troponin testing in the office setting is classified as Class 3: Harm 1, 2

Critical Pitfalls to Avoid

Do Not Rely on These to Exclude ACS

• Nitroglycerin response: Relief with nitroglycerin neither confirms nor excludes myocardial ischemia—esophageal spasm also responds 3, 2
• Reproducible chest wall tenderness: 7% of patients with palpable tenderness have ACS 2
• Sharp or pleuritic pain: Does not exclude ACS—pericarditis and atypical presentations occur 1, 2
• Young age: ACS can occur even in adolescents without traditional risk factors 2

Do Not Delay Transfer

• Never delay ED transfer to obtain troponin or other diagnostic testing in the office—this is explicitly harmful 1, 2
• Even low-risk patients cannot be safely discharged without objective testing (ECG and troponin) 2

Special Considerations for Pulmonary Embolism

When to Suspect PE

• Sudden dyspnea with pleuritic chest pain, particularly with risk factors (recent surgery, immobilization, malignancy, prior VTE) 3, 5
• Be aware: Massive PE can mimic STEMI with ST-segment elevation on ECG 6, 7, 8
• If PE is suspected and patient is hemodynamically stable, refer to ED for D-dimer testing and chest imaging 5

Why EMS Transport is Mandatory for Suspected ACS

EMS provides critical advantages over personal vehicle transport:

• Prehospital ECG acquisition reduces mortality and in-hospital delay 3, 2
• Trained personnel can administer aspirin, provide defibrillation, and manage complications en route 3, 2
• Shorter time to definitive care 2