What is the appropriate assessment and management approach for a patient presenting with chest pain in a primary care clinic, considering their age, sex, underlying medical conditions, and associated symptoms?

Comprehensive Approach to Chest Pain in Primary Care

When a patient presents with chest pain in your primary care clinic, your immediate priority is to rapidly identify or exclude life-threatening causes—particularly acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism—through focused history, immediate ECG acquisition, and risk stratification to determine whether emergency department transfer is required. 1

Immediate Actions Upon Presentation

First 10 Minutes

• Obtain a 12-lead ECG within 10 minutes of the patient reporting chest pain, regardless of your initial clinical impression 1, 2
• If your office lacks ECG capability, refer immediately to the emergency department 2
• Do not order troponin in the office setting if ACS is suspected—instead, activate emergency medical services (EMS) for transport to the ED for definitive testing 2, 3
• If ACS cannot be excluded based on clinical presentation, activate EMS for transport rather than allowing self-transport 2, 3

Critical Red Flags Requiring Immediate ED Transfer

• ST-segment elevation, new left bundle branch block, Q waves, or new T-wave inversions on ECG 1
• Sudden-onset "ripping" or "tearing" chest pain radiating to the back (suggests aortic dissection) 1, 3
• Pulse differential between extremities or blood pressure differential >20 mmHg (aortic dissection) 1
• Severe pain with abrupt onset plus pulse differential plus widened mediastinum on chest X-ray (>80% probability of dissection) 1
• Chest pain with syncope, severe dyspnea, or hemodynamic instability 1, 3

Focused History: What You Must Ask

Pain Characteristics (Use This Exact Framework)

Nature of pain: 1

• Anginal symptoms: retrosternal discomfort described as pressure, heaviness, tightness, squeezing, or constriction
• Red flag: Sharp pain that increases with inspiration and lying supine is unlikely ischemic (suggests pericarditis)
• Red flag: Fleeting pain lasting only seconds is unlikely ischemic
• Red flag: Pain localized to a very small area or radiating below the umbilicus is unlikely ischemic

Onset and duration: 1

• Anginal symptoms build gradually over several minutes
• Red flag: Sudden-onset ripping pain suggests aortic dissection, not ACS
• Symptoms at rest or with minimal exertion suggest ACS rather than stable angina

Location and radiation: 1

• Classic angina: retrosternal with radiation to left arm, neck, jaw, shoulders, or upper abdomen
• Red flag: Radiation to upper or lower back suggests aortic dissection

Precipitating factors: 1

• Physical exertion or emotional stress are common anginal triggers
• Occurrence at rest or with minimal exertion indicates ACS
• Positional chest pain is usually nonischemic (musculoskeletal)

Associated symptoms: 1, 2

• Dyspnea, palpitations, diaphoresis, lightheadedness, presyncope/syncope, nausea, vomiting
• Women, elderly patients, and diabetics may present with throat/abdominal discomfort, jaw pain, back pain, or epigastric symptoms rather than classic chest pain 2, 4

Critical Pitfall to Avoid

Do NOT use nitroglycerin response as a diagnostic criterion for cardiac ischemia—esophageal spasm and GERD can also respond to nitroglycerin 1, 3, 5

Risk Stratification by Age and Sex

Age-Specific Considerations 4

• Ages 18-44: Musculoskeletal causes most common, but ACS cannot be excluded based on age alone
• Ages 45-64: Increasing prevalence of ACS; cardiac causes become more likely
• Ages 65-79: High likelihood of cardiac etiology; maintain lower threshold for cardiac workup
• Age ≥80: Very high risk; atypical presentations common (dyspnea, syncope, delirium, unexplained falls rather than chest pain)

Sex-Specific Considerations 2, 3

• Women aged 40-49 with anginal symptoms have <10% pretest probability of obstructive CAD in stable settings 2
• However, women face systematic underdiagnosis because risk tools underestimate their cardiac risk and symptoms are misclassified as noncardiac 2
• Maintain a lower threshold for cardiac evaluation in women with any concerning features, particularly those with cardiovascular risk factors 2
• Women more commonly present with accompanying symptoms: jaw/neck pain, back pain, epigastric symptoms, shortness of breath, nausea, diaphoresis 2, 3

Physical Examination: What to Look For

Life-Threatening Conditions 1

ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur (examination may be normal in uncomplicated cases)

Aortic dissection: Marfan syndrome features, pulse differential between extremities (30% of patients), blood pressure differential, syncope (>10% of patients), aortic regurgitation murmur (40-75% in type A)

Pulmonary embolism: Tachycardia plus dyspnea (>90% of patients), pain with inspiration

Tension pneumothorax: Dyspnea, pain on inspiration, unilateral absence of breath sounds

Non-Life-Threatening Conditions 1

Pericarditis: Fever, pleuritic chest pain increased in supine position, friction rub

Costochondritis: Tenderness of costochondral joints, reproducible with palpation

Pneumonia: Fever, localized chest pain (may be pleuritic), regional dullness to percussion, egophony

GERD/peptic ulcer: Right upper quadrant tenderness, Murphy sign

Differential Diagnosis Algorithm

Life-Threatening (Rule Out First) 3

1. Acute coronary syndrome (STEMI, NSTE-ACS, unstable angina)
2. Aortic dissection
3. Pulmonary embolism
4. Tension pneumothorax
5. Esophageal rupture

Common Non-Life-Threatening Causes 1, 3

• Musculoskeletal/chest wall pain (42% of nontraumatic chest pain; most common in primary care)
• Gastroesophageal reflux disease
• Costochondritis
• Anxiety/panic disorder
• Pneumonia
• Pericarditis

When to Transfer vs. Evaluate in Office

Transfer to ED Immediately (via EMS): 2, 3

• Any ECG changes suggesting ACS
• Clinical suspicion of ACS that cannot be excluded
• Suspected aortic dissection, PE, or other life-threatening cause
• Hemodynamic instability
• Persistent symptoms despite initial assessment

Can Evaluate in Office (Low-Risk Patients): 1

• Low-risk patients determined by structured risk assessment do not need urgent diagnostic testing for suspected CAD
• Reproducible chest wall tenderness with normal vital signs and no concerning history
• Clear musculoskeletal etiology with normal ECG
• Chronic, stable symptoms with low pretest probability

Serial ECG Monitoring 1

If initial ECG is nondiagnostic but clinical suspicion remains high, perform serial ECGs to detect evolving ischemic changes, especially when:

• Symptoms are persistent
• Clinical condition deteriorates
• High clinical suspicion despite initial normal ECG

Special Populations

Elderly Patients (≥75 years) 4, 3

• Account for approximately 33% of all ACS cases
• Often present with atypical symptoms: shortness of breath, syncope, acute delirium, unexplained falls
• Maintain lower threshold for cardiac evaluation
• Age ≥75 is itself a major risk factor for ACS

Women 2, 3

• Chest pain is still the dominant symptom in women with ACS, but accompanying symptoms are more common
• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac workup is negative
• Risk assessment tools systematically underestimate cardiac risk in women

Diabetic Patients 1

• May present with atypical symptoms including throat or abdominal discomfort
• Higher likelihood of silent ischemia
• Lower threshold for cardiac evaluation

Common Pitfalls to Avoid

1. Do not use "atypical" to describe chest pain—this terminology is misleading and based on male presentation patterns; use "cardiac," "possible cardiac," or "noncardiac" instead 1

2. Do not assume low risk based on age or sex alone—young patients and women can have ACS 2, 4

3. Do not delay ED transfer to obtain troponin in office—if ACS is suspected, activate EMS immediately 2, 3

4. Do not use nitroglycerin response diagnostically—GERD and esophageal spasm can also respond 1, 3, 5

5. Do not assume symptoms are noncardiac based on "atypical" presentation, especially in elderly women and diabetics 2, 4, 3

6. Do not order routine cardiac testing for low-risk patients—use structured risk assessment to guide testing 1

Documentation Essentials

Document all components of focused history (nature, onset, duration, location, radiation, precipitating factors, relieving factors, associated symptoms), cardiovascular risk factors, physical examination findings including vital signs and focused cardiac/pulmonary exam, ECG interpretation and time obtained, risk stratification assessment, and decision-making rationale for ED transfer vs. office evaluation 1, 6, 7