What is the recommended initial assessment and management approach for a patient presenting with chest pain?

Approach to Chest Pain

Obtain a 12-lead ECG within 10 minutes of patient arrival and measure cardiac troponin immediately to identify or exclude life-threatening causes—acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, and esophageal rupture—which can progress to death within minutes to hours without urgent intervention. 1, 2

Immediate Actions (First 10 Minutes)

Mandatory Initial Assessment

• Acquire and interpret a 12-lead ECG within 10 minutes to detect ST-elevation myocardial infarction (≥1 mm ST-elevation in contiguous leads), ST-depression, T-wave inversions, or pericarditis patterns (diffuse ST-elevation with PR-depression). 1, 2

• Draw high-sensitivity cardiac troponin immediately when any suspicion of acute coronary syndrome exists; this is the most sensitive and specific biomarker for myocardial injury. 1, 2

• Assess vital signs promptly: heart rate, blood pressure in both arms (to detect pulse/BP differentials suggesting aortic dissection), respiratory rate, and oxygen saturation. 1, 2

• Perform a focused cardiovascular examination looking for diaphoresis, tachypnea, tachycardia, hypotension, pulmonary crackles, S3 gallop, new murmurs (mitral regurgitation or aortic regurgitation), pericardial friction rub, unilateral absent breath sounds, pulse differentials between extremities, and jugular venous distension. 1, 2

Pre-Hospital Management

• Activate emergency medical services (EMS) immediately for any suspected life-threatening cause; do not transport by personal automobile. 1, 2

• Administer aspirin 162–325 mg (chewed, not swallowed) in alert adults without known allergy or active gastrointestinal bleeding while awaiting EMS. 1, 2

• Provide sublingual nitroglycerin unless systolic blood pressure <90 mmHg or heart rate <50 or >100 bpm. 1

• Administer intravenous morphine 4–8 mg (with additional 2 mg doses every 5 minutes as needed) for pain relief, as pain increases sympathetic activation and myocardial workload. 1

• Give supplemental oxygen 2–4 L/min only if the patient is breathless, has heart failure features, or oxygen saturation is low; routine oxygen in normoxemic patients may be harmful. 1

Life-Threatening Diagnoses to Exclude First

Acute Coronary Syndrome (ACS)

• Clinical presentation: Retrosternal pressure, squeezing, heaviness, or tightness that builds gradually over several minutes (not instantaneously), often radiating to left arm, neck, or jaw. 1, 2, 3

• Associated symptoms: Diaphoresis, dyspnea, nausea, vomiting, lightheadedness, presyncope, or syncope. 1, 2

• Physical findings: May include tachycardia, hypotension, crackles, S3 gallop, or new mitral regurgitation murmur; a completely normal examination does not exclude uncomplicated myocardial infarction. 1, 2, 3

• ECG-directed management:

  • STEMI present (ST-elevation ≥1 mm in contiguous leads): Activate STEMI protocol immediately; aim for primary PCI with door-to-balloon <90 minutes or fibrinolysis with door-to-needle <30 minutes. 1, 2
  • ST-depression or T-wave inversions (NSTE-ACS): Admit to coronary care unit, provide continuous cardiac monitoring, dual antiplatelet therapy (aspirin plus P2Y12 inhibitor), anticoagulation, and plan urgent coronary angiography. 1, 2
  • Initial ECG nondiagnostic but high clinical suspicion: Perform serial ECGs every 15–30 minutes to detect evolving ischemic changes; consider posterior leads V7–V9 to rule out posterior MI. 1, 2

• Troponin interpretation: Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours) after initial sample to improve diagnostic accuracy; a single high-sensitivity troponin below the limit of detection in patients with symptom onset ≥3 hours before arrival and normal ECG is sufficient to exclude myocardial injury. 2

Acute Aortic Dissection

• Clinical presentation: Sudden-onset severe "ripping" or "tearing" chest or back pain that is maximal at onset. 1, 2, 3

• Physical findings: Pulse differential between extremities (present in ~30% of cases, more common in type A dissections), systolic blood pressure difference >20 mmHg between arms, new aortic regurgitation murmur (present in 40–75% of type A dissections). 1, 2, 3

• Risk factors: Hypertension, known bicuspid aortic valve, aortic dilation, connective tissue disorders (Marfan syndrome). 1, 2

• Diagnostic clue: The combination of severe abrupt pain, pulse differential, and widened mediastinum on chest X-ray confers >80% probability of dissection. 2, 3

• Management: Withhold antithrombotic therapy (aspirin, heparin) if aortic dissection is suspected; transfer immediately to a center with 24/7 aortic imaging and cardiac surgery. 1

Pulmonary Embolism (PE)

• Clinical presentation: Sudden dyspnea with pleuritic chest pain (worsens with inspiration). 1, 2, 3

• Physical findings: Tachycardia (present in >90% of patients), tachypnea. 1, 2, 4

• Risk stratification: Use validated clinical decision rules (Wells criteria) to determine pre-test probability; in low-to-intermediate probability patients, obtain D-dimer using age- and sex-specific cutoffs (a negative D-dimer effectively rules out PE). 1, 4

• Imaging: For high clinical suspicion or positive D-dimer, proceed directly to CT pulmonary angiography. 1, 4

• Management: Transfer stable patients to emergency department or chest pain unit; transfer patients with severe symptoms, hemodynamic instability (cardiac arrest, syncope, shock), or right ventricular enlargement on echocardiography to intensive care units in centers equipped for thrombectomy. 1

Tension Pneumothorax

• Clinical presentation: Dyspnea and sharp chest pain that intensifies on inspiration. 2, 3, 4

• Physical findings: Unilateral absence or marked reduction of breath sounds, hyperresonant percussion, tracheal deviation, hemodynamic instability (hypotension, tachycardia). 1, 2, 3

Pericardial Tamponade

• Clinical presentation: Pleuritic chest pain that worsens when lying supine. 1, 2

• Physical findings: Jugular vein distension, signs of cardiogenic shock, hemodynamic instability (heart rate >130 or <40 bpm, systolic blood pressure <90 mmHg), respiratory distress (respiratory rate >25, oxygen saturation <90%), low voltage and/or electrical alternans on ECG. 1

• Management: Rapid transfer to nearest center with ultrasound-guided pericardiocentesis and/or cardiac surgery on-site is mandatory; ultrasound-guided pericardiocentesis may be considered in the pre-hospital setting if expertise is available. 1

Esophageal Rupture (Boerhaave Syndrome)

• Clinical presentation: History of forceful vomiting preceding chest pain. 2, 3

• Physical findings: Subcutaneous emphysema on neck or chest examination, pneumothorax (occurs in ~20% of cases), unilateral decreased or absent breath sounds. 2, 3

Risk Stratification After Initial Assessment

High-Risk Features Requiring Immediate Coronary Care Unit Admission

• Prolonged ongoing rest pain (>20 minutes). 1
• Hemodynamic instability (systolic blood pressure <100 mmHg, heart rate >100 or <50 bpm). 1, 2
• Severe continuing pain with ischemic ECG changes. 1
• Elevated troponin above the 99th percentile. 1, 2
• Left ventricular failure or other hemodynamic abnormalities (crackles, S3 gallop, new murmurs). 1

Intermediate-Risk Features

• Prior history of myocardial infarction or coronary artery disease. 2
• Age >70 years (or ≥75 years with accompanying symptoms such as dyspnea, syncope, acute delirium, or unexplained falls). 1, 2
• Diabetes mellitus, hypertension, hyperlipidemia, smoking, family history of premature coronary artery disease. 1, 2
• Rest angina >20 minutes that has resolved. 2

Low-Risk Patients (Suitable for Chest Pain Unit Observation)

• Normal or nondiagnostic ECG. 1, 2
• Negative troponin at presentation and at 6–12 hours after symptom onset. 1, 2
• No high-risk features (stable vital signs, no ongoing pain, no heart failure signs). 1, 2
• Management: Observe in chest pain unit for 10–12 hours or discharge for outpatient stress testing within 72 hours. 1, 2

Critical Historical Features to Obtain

Pain Characteristics That Increase ACS Likelihood

• Quality: Pressure, squeezing, gripping, heaviness, tightness, or constriction (patients rarely use the word "pain" itself). 2, 3
• Onset: Gradual build over several minutes, not instantaneous. 1, 2, 3
• Location and radiation: Retrosternal with radiation to left arm, neck, jaw, or between shoulder blades. 1, 2, 3
• Duration: Several minutes; fleeting pain lasting only seconds is unlikely to be ischemic. 1, 2
• Precipitating factors: Physical exertion or emotional stress. 1, 2
• Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, lightheadedness, presyncope, syncope. 1, 2

Pain Characteristics Suggesting Non-Ischemic Etiology

• Sharp, stabbing, fleeting pain lasting only seconds. 1, 2, 3
• Pleuritic (worsens with inspiration) and positional (worsens lying supine, improves sitting forward) suggests pericarditis. 1, 2, 4
• Localized to a very small area or radiating below the umbilicus. 1, 2
• Reproducible with palpation or affected by breathing, turning, twisting, or bending suggests costochondritis. 2, 3, 4

Important caveat: Sharp, pleuritic pain does not completely exclude ACS; 13% of patients with acute myocardial ischemia present with pleuritic features, and 7% of patients with reproducible chest wall tenderness still have ACS. 2, 3, 4

Special Population Considerations

Women

• Higher risk of underdiagnosis: Women are more likely to present with accompanying symptoms rather than classic chest pain. 1, 2
• Key accompanying symptoms: Jaw or neck pain (10% vs ~4% in men), nausea or vomiting (32% vs 23% in men), epigastric discomfort, palpitations, inter-scapular pain (62% vs ~55% in men), dyspnea, fatigue, shortness of breath. 2
• Use sex-specific troponin thresholds: High-sensitivity troponin I >16 ng/L for women vs >34 ng/L for men; this reclassifies ~30% of women as having STEMI who would be missed with a universal cutoff. 2
• Actively inquire about accompanying symptoms during assessment to avoid missing ACS. 2

Older Adults (≥75 Years)

• Atypical presentations: May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain. 1, 2
• ACS should be considered when these accompanying symptoms are present. 1, 2

Patients with Diabetes

• More likely to present with atypical symptoms: Vague abdominal symptoms, confusion, or isolated dyspnea. 2
• Higher risk for silent ischemia. 2

Common Pitfalls to Avoid

• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain; esophageal spasm and other conditions also respond to nitroglycerin. 1, 2, 3, 4

• Do not dismiss chest pain in women, elderly patients, or individuals with diabetes based on atypical presentations; these populations frequently present without classic symptoms. 1, 2

• Do not assume a normal physical examination excludes ACS; uncomplicated myocardial infarction can present with a completely normal exam. 1, 2, 3

• Do not delay transfer to the emergency department for troponin testing in office settings when ACS is suspected; patients with clinical evidence of ACS or other life-threatening causes should be transported urgently by EMS. 1, 2

• Do not use the term "atypical chest pain"; instead describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1, 2

• A normal initial ECG does not exclude ACS; 30–40% of acute myocardial infarctions present with a normal or non-diagnostic ECG, and ~5% of ACS patients have a normal initial ECG. 1, 2, 4

• Chest wall tenderness does not exclude serious pathology; 7% of patients with reproducible chest wall tenderness have ACS. 3, 4

Alternative Diagnoses After Excluding Life-Threatening Causes

Pericarditis

• Clinical features: Sharp, pleuritic chest pain that worsens when supine and improves when leaning forward, fever, pericardial friction rub. 1, 2, 3, 4
• ECG findings: Diffuse concave ST-elevation with PR-depression. 2, 4
• Management: High-dose aspirin (500 mg–1 g every 6–8 hours) or ibuprofen (600–800 mg three times daily for 1–2 weeks) plus colchicine (0.5–0.6 mg once or twice daily for ~3 months). 1, 4

Costochondritis/Tietze Syndrome

• Clinical features: Tenderness over costochondral joints on palpation, pain reproducible with chest wall pressure, affected by breathing, turning, twisting, or bending. 2, 3, 4
• Prevalence: Accounts for ~43% of chest pain presentations in primary care after cardiac causes are excluded. 2, 3
• Management: NSAIDs (ibuprofen 600–800 mg three times daily), avoidance of aggravating movements. 2

Gastroesophageal Reflux Disease (GERD)

• Clinical features: Burning retrosternal pain related to meals or at night, worsened by stress, often relieved by antacids. 2, 3
• Management: Empiric proton-pump inhibitor trial. 3

Pneumonia

• Clinical features: Fever, localized pleuritic pain, productive cough, regional dullness to percussion, egophony, possible pleural friction rub. 2, 3, 4

Herpes Zoster

• Clinical features: Dermatomal pain triggered by light touch, followed by characteristic unilateral dermatomal vesicular rash. 2, 3

Setting-Specific Recommendations

Office/Outpatient Setting

• If an ECG is unavailable, refer the patient to the emergency department immediately so one can be obtained. 1

• If clinical evidence of ACS or other life-threatening causes exists, transport urgently to the emergency department by EMS; do not delay transfer for troponin or other diagnostic testing. 1, 2

Emergency Department

• Utilize clinical decision pathways (e.g., TIMI, GRACE scores) routinely for chest pain evaluation. 2

• Engage in shared decision-making with clinically stable patients regarding testing options, considering radiation exposure and cost. 2

• Transfer patients with cardiac arrhythmia to a facility with continuous ECG monitoring (emergency department, chest pain unit, intensive or continuous care unit). 1