What is the best approach to diagnose and treat a patient with chest pain and relevant medical history?

Pertinent Positive and Negative Findings for Chest Pain

When evaluating chest pain, immediately focus on identifying or excluding life-threatening causes through specific historical features, physical examination findings, and diagnostic testing within the first 10 minutes of patient contact. 1, 2

Critical Pertinent Positives (Red Flags Requiring Immediate Action)

Pain Characteristics Suggesting Acute Coronary Syndrome

• Retrosternal pressure, squeezing, gripping, heaviness, or tightness building gradually over minutes (not instantaneous onset) 1, 2, 3
• Radiation to left arm, neck, jaw, shoulders, or back 1, 2, 3
• Pain lasting >20 minutes at rest or with minimal exertion 2, 3
• Note: Pain, pressure, tightness, or discomfort in shoulders, arms, neck, back, upper abdomen, or jaw should ALL be considered anginal equivalents—not just chest pain itself 1

Associated Symptoms Increasing ACS Likelihood

• Diaphoresis (sweating) 2, 3, 4
• Dyspnea or shortness of breath 1, 2
• Nausea and vomiting 1, 2, 3
• Lightheadedness, presyncope, or syncope 2, 3
• Fatigue (particularly in women) 1

Pain Characteristics Suggesting Aortic Dissection

• Sudden-onset "ripping" or "tearing" chest pain radiating to upper or lower back 2, 3
• Pulse differentials between extremities 3, 5
• Blood pressure differentials >20 mmHg between arms 3, 5

Pain Characteristics Suggesting Pulmonary Embolism

• Acute dyspnea with pleuritic chest pain 1, 3, 5
• Tachycardia (present in >90% of cases) 3, 5
• Tachypnea 3, 5
• Associated risk factors (recent surgery, immobilization, malignancy, pregnancy) 2, 3

Pain Characteristics Suggesting Pericarditis

• Sharp, pleuritic chest pain that worsens when supine and improves when leaning forward 1, 3, 5
• Pain worsens with inspiration and coughing 3, 5
• Pericardial friction rub on examination 1, 3

High-Risk Patient Features

• Age >75 years with accompanying symptoms (dyspnea, syncope, acute delirium, unexplained falls) 2, 3
• Women presenting with atypical symptoms (nausea, fatigue, jaw/neck/back pain without classic chest pain) 1, 2
• Diabetes mellitus (higher risk for silent ischemia and atypical presentations) 2, 3
• Known coronary artery disease, prior MI, or revascularization 2, 3

Critical Physical Examination Findings

• Hemodynamic instability (hypotension, shock) 1, 2, 3
• New cardiac murmur (suggesting acute valvular dysfunction or ventricular septal defect) 1, 2
• S3 gallop (suggesting heart failure or myocarditis) 1, 2
• Crackles on lung examination (suggesting pulmonary edema) 2
• Unilateral absence of breath sounds with hyperresonant percussion (suggesting pneumothorax) 3, 5

Critical Pertinent Negatives (Features Reducing Likelihood of ACS)

Pain Characteristics Less Likely to Represent ACS

• Sharp, stabbing, or fleeting pain lasting only seconds 1, 2, 3
• Pain localized to a very small area (can point with one finger) 2, 3
• Pleuritic pain that worsens with inspiration (makes ischemic heart disease less likely but does NOT exclude it) 1, 2, 5
• Pain reproducible with chest wall palpation 3, 5
• Pain that radiates below the umbilicus 3
• Positional pain (worse with specific body positions) 3, 5

Important Caveats About "Reassuring" Features

• CRITICAL PITFALL: 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome 5
• Sharp, pleuritic pain does NOT exclude ACS—13% of ACS patients present with pleuritic pain 5
• Young age does NOT exclude ACS—it can occur even in adolescents without risk factors 2
• Relief with nitroglycerin should NEVER be used as a diagnostic criterion, as esophageal spasm and other noncardiac conditions also respond to nitroglycerin 2, 3, 5, 6

Low-Risk Historical Features

• Absence of cardiovascular risk factors (no diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD) 2, 3
• Age <40 years without risk factors (but still requires evaluation) 2
• Clear relationship to meals with burning quality (suggesting GERD) 3
• Chronic, stable, reproducible symptoms without change in pattern 2, 3

Mandatory Initial Assessment (Within 10 Minutes)

Essential Diagnostic Testing

• 12-lead ECG within 10 minutes of arrival to identify STEMI, ST depression, T-wave inversions, or pericarditis patterns 1, 2, 4
• Serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains high 1, 2
• High-sensitivity cardiac troponin measurement as soon as possible 1, 2
• Supplemental leads V7-V9 reasonable if posterior MI suspected (left circumflex or right coronary artery occlusion) 1

Critical Physical Examination Components

• Vital signs including oxygen saturation and blood pressure in both arms 2, 5
• Cardiovascular examination for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new murmurs 2
• Pulse examination for differentials 3, 5
• Lung examination for unilateral decreased breath sounds 3, 5

Algorithmic Approach to Risk Stratification

If ANY of the following are present, immediate ED transfer by EMS is mandatory (do NOT delay for office-based testing): 1, 2

• ST-elevation or new ischemic changes on ECG
• Hemodynamic instability
• Ongoing chest pain with high-risk features
• Age >75 with accompanying symptoms
• Clinical evidence of acute aortic syndrome or pulmonary embolism

If ECG shows ST-elevation or new left bundle branch block: Treat as STEMI immediately per STEMI guidelines 1, 2

If ECG shows ST-depression or new T-wave inversions: Follow NSTE-ACS guidelines 1, 2

If initial ECG is nondiagnostic but symptoms persist: Repeat ECG every 5-10 minutes until symptoms resolve or other diagnostic testing excludes ACS 1, 2

For low-risk patients with normal ECG and negative troponin: Urgent diagnostic testing for suspected coronary artery disease is not routinely needed, but structured risk assessment using evidence-based protocols should guide disposition 1

Special Population Considerations

Women

• More likely to present with accompanying symptoms rather than classic chest pain (nausea, fatigue, dyspnea, jaw/neck/back pain) 1, 2
• At higher risk for underdiagnosis of ACS 2, 3

Elderly (≥75 years)

• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls WITHOUT classic chest pain 2, 3
• Higher threshold for admission and testing required 2, 3

Diabetic Patients

• More likely to present with atypical symptoms (vague abdominal symptoms, confusion, isolated dyspnea) 2
• Higher risk for silent ischemia 2

Terminology to Use and Avoid

Use "noncardiac" if heart disease is not suspected—NEVER use "atypical," which is a misleading descriptor that can lead to underdiagnosis 1