How should I evaluate and manage a burning chest sensation in an adult?

Evaluation and Management of Burning Chest Sensation in Adults

Immediately activate emergency medical services (EMS) for any adult with acute burning chest sensation, as this represents a potential acute coronary syndrome (ACS) requiring rapid triage and ECG within 5-10 minutes of first contact. 1, 2

Initial Assessment and Risk Stratification

Characterize the burning sensation immediately to determine cardiac vs. noncardiac origin:

• Cardiac features: Substernal burning provoked by exertion or emotional stress, relieved by rest, radiating to jaw/arm/back, associated with diaphoresis, nausea, or dyspnea 1
• Lower probability features: Sharp, fleeting, pleuritic (worse with breathing), positional, point tenderness, or shifting locations 1
• Avoid the term "atypical" - instead classify as cardiac, possibly cardiac, or noncardiac, as "atypical" is misleading and can result in dangerous underdiagnosis 1

Women require heightened vigilance as they are at significant risk for underdiagnosis and may present with burning accompanied by nausea, fatigue, jaw pain, or epigastric discomfort rather than classic pressure 1, 2

Immediate Actions for Suspected Cardiac Origin

While awaiting EMS arrival:

• Administer aspirin 162-325 mg (chewed, not swallowed) unless the patient has known aspirin allergy, active bleeding, or has been advised by a physician not to take aspirin 1, 2
• If any uncertainty exists about aspirin contraindications, wait for EMS arrival without administration 1
• Do NOT administer oxygen unless the patient is hypoxic 1

Obtain 12-lead ECG within 5-10 minutes to identify ST-segment elevation myocardial infarction (STEMI), ST-segment depression, T-wave inversions, or other ischemic changes 2

Risk Stratification Framework

High-risk features requiring immediate hospital transfer: 2

• Prolonged ongoing rest pain >20 minutes
• Associated diaphoresis, dyspnea, nausea, or syncope
• ST-segment elevation or depression on ECG 2

Intermediate-risk features: 2

• Prior myocardial infarction or known coronary artery disease
• Age >70 years
• Diabetes mellitus or renal insufficiency
• Abnormal ECG without clear ischemia (bundle branch blocks) 3

Low-risk features: 4, 5

• Normal ECG with upright T waves and isoelectric ST segments
• Two negative serial troponin measurements
• Normal vital signs
• HEART score ≤2 or TIMI score 0-1

Diagnostic Testing Algorithm

For patients with normal initial ECG but ongoing concern: 2, 6

• Serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains
• Serial troponin measurements at 0 and 2-3 hours (for high-sensitivity troponin) or 0 and 6-12 hours (for conventional troponin) 6
• Symptoms must have started at least 3 hours before first troponin measurement for single-measurement rule-out with high-sensitivity assays 6

Patients with normal ECG have extremely low risk - only 1.3% subsequently diagnosed with myocardial infarction in one study, compared to 54.2% of those with ischemic ECG changes 3

Disposition Decisions

Immediate reperfusion required for STEMI: 2

• Primary percutaneous coronary intervention (PCI) with door-to-balloon time <90 minutes preferred
• Fibrinolytic therapy with door-to-needle time <30 minutes if PCI unavailable

Admit to coronary care unit with continuous monitoring: 2

• Elevated troponin without ST-elevation (NSTEMI/Unstable Angina)
• Abnormal ECG with ischemic changes

Safe for discharge with outpatient follow-up within 1-2 weeks: 6, 4, 5

• HEART score ≤2 or TIMI score 0-1
• Non-ischemic ECG
• Negative serial troponin measurements
• No ongoing symptoms
• Normal vital signs

The incidence of clinically relevant adverse cardiac events in hospitalized chest pain patients with two negative troponins and non-ischemic ECG is only 0.06%, suggesting routine admission may not benefit this low-risk group 4

Special Population Considerations

Women: 1, 2

• Actively inquire about accompanying symptoms (nausea, fatigue, jaw pain, epigastric discomfort)
• Maintain high index of suspicion as they are at risk for underdiagnosis
• Chest pain is still the most common symptom of ACS in women

Elderly patients (≥75 years): 2

• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls
• Classic burning chest sensation may be absent

Young patients: 2

• Do not assume young age excludes ACS
• Can occur in adolescents without traditional risk factors

Critical Pitfalls to Avoid

Do NOT use nitroglycerin response as a diagnostic tool - esophageal spasm and other noncardiac conditions may also respond to nitroglycerin 2

Do NOT delay transfer to ED for troponin testing in office settings when ACS is suspected 2

Do NOT rely on point tenderness to exclude cardiac origin - while it suggests lower likelihood, it does not definitively rule out ischemia 1

Do NOT discharge patients without ensuring follow-up within 1-2 weeks if they meet low-risk criteria; if follow-up unavailable, consider further testing or observation 6

Noncardiac Causes

If cardiac causes are excluded, consider gastroesophageal reflux disease (GERD) as the most common noncardiac cause of burning chest sensation 7:

• GERD accounts for approximately half of noncardiac chest pain cases
• Can be effectively treated with proton-pump inhibitors
• May coexist with cardiac disease in the same patient 7

Psychological factors (depression, panic disorder) can cause or worsen chest pain of any origin and complicate clinical assessment 7