In an outpatient family clinic without ECG capability, how should I evaluate and manage a patient presenting with acute chest pain to promptly exclude life‑threatening causes before considering a benign musculoskeletal diagnosis?

Acute Chest Pain Evaluation Without On-Site ECG

Without on-site ECG capability, you must immediately transfer any patient with acute chest pain to the emergency department by EMS—do not attempt office-based evaluation or delay transfer for additional testing. 1

Immediate Actions in Your Office

1. Activate EMS Transport Immediately

• Call 911 for EMS transport rather than allowing the patient to drive or be driven by family because EMS can acquire a prehospital ECG (which facilitates reperfusion if STEMI is present), provide treatment for arrhythmias and chest pain en route, implement defibrillation if needed, and achieve shorter travel times to the ED. 1

• Personal automobile transport is associated with increased risk and should be avoided. 1

2. While Awaiting EMS Arrival

• Give aspirin 162–325 mg (chewed, not swallowed) immediately unless the patient has a known aspirin allergy or active gastrointestinal bleeding. 1, 2

• Administer sublingual nitroglycerin unless systolic blood pressure is <90 mmHg or heart rate is <50 bpm or >100 bpm. 1, 2

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

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

Critical History Elements to Document Before Transfer

High-Risk Pain Characteristics

• Retrosternal pressure, squeezing, gripping, heaviness, or tightness that builds gradually over several minutes (not instantaneously) strongly suggests acute coronary syndrome. 1, 2

• Radiation to the left arm, neck, jaw, or between the shoulder blades increases the likelihood of ACS. 1, 2

• Sudden "ripping" or "tearing" pain radiating to the back is characteristic of aortic dissection. 1, 2

• Sudden dyspnea with pleuritic chest pain (worsening on inspiration) suggests pulmonary embolism. 1, 2

Associated Symptoms That Mandate Urgent Transfer

• Diaphoresis, dyspnea, nausea, vomiting, light-headedness, presyncope, or syncope all increase the probability of ACS. 1, 2

• In women specifically: jaw/neck pain, nausea, fatigue, epigastric discomfort, and back pain are common ACS presentations. 1, 2

• In older adults (≥75 years): isolated dyspnea, syncope, acute delirium, or unexplained falls may be the only manifestations of ACS. 1, 2, 3

Cardiovascular Risk Factors to Document

• Age, sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, and family history of premature coronary artery disease should all be noted. 2

Focused Physical Examination Findings to Document

High-Risk Findings Requiring Immediate EMS Transfer

• Hemodynamic instability: systolic blood pressure <100 mmHg, heart rate >100 bpm or <50 bpm. 2

• Heart-failure signs: pulmonary crackles, S3 gallop, elevated jugular venous pressure. 2

• New murmurs: mitral regurgitation (suggesting papillary-muscle dysfunction) or aortic regurgitation (suggesting dissection). 2

• Pulse differential between extremities (assess all four limbs)—present in ~30% of aortic dissections. 2

• Unilateral absent or markedly reduced breath sounds indicate pneumothorax or massive pleural effusion. 2

• Subcutaneous emphysema points toward esophageal rupture or pneumomediastinum. 2

What NOT to Do

• Do NOT delay transfer to obtain troponin or other diagnostic testing in your office—delayed transfer for additional testing beyond the ECG is detrimental and should be avoided. 1, 2

• Do NOT rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain—esophageal spasm and other conditions may also respond. 2, 4

• Do NOT assume a young age or absence of risk factors excludes ACS—underdiagnosis occurs across all age groups. 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

Why ECG Within 10 Minutes Is Mandatory

• The 12-lead ECG must be acquired and interpreted within 10 minutes of arrival to any medical facility to identify STEMI and enable urgent coronary reperfusion. 1, 2

• Early recognition of STEMI improves outcomes—door-to-balloon time for primary PCI must be <90 minutes, and door-to-needle time for fibrinolysis must be <30 minutes. 1, 2

• A substantial proportion of patients with chest pain are transferred to the ED without a prehospital ECG, resulting in avoidable delays in readiness of the ED and reperfusion teams. 1

• If an ECG cannot be obtained in your office setting, immediate transfer to the ED by EMS is recommended. 1

Life-Threatening Diagnoses That Must Be Excluded in the ED

The emergency department must promptly rule out six conditions that can be fatal within minutes to hours:

1. Acute coronary syndrome (ACS) 2
2. Aortic dissection 2
3. Pulmonary embolism 2
4. Tension pneumothorax 2
5. Esophageal rupture 2
6. Pericardial tamponade 2

Special Populations at High Risk for Underdiagnosis

Women

• Women are at high risk for underdiagnosis of ACS and more frequently present with accompanying symptoms rather than classic chest pain. 1, 2

• Key accompanying symptoms in women: nausea, fatigue, dyspnea, jaw pain, neck pain, back pain, and epigastric discomfort. 1, 2

Older Adults

• Patients aged ≥75 years may present with atypical symptoms such as isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain. 1, 2, 3

Patients with Diabetes

• Patients with diabetes are more likely to present with atypical symptoms, including vague abdominal symptoms, confusion, or isolated dyspnea, and have a higher risk for silent ischemia. 2

Common Pitfalls That Lead to Missed Diagnoses

• A normal physical examination does NOT exclude ACS—uncomplicated myocardial infarction can present with a completely normal exam. 2

• Sharp, pleuritic pain does NOT exclude ACS—pericarditis and atypical presentations can occur, and 13% of patients with pleuritic features still have acute myocardial ischemia. 2

• A normal initial ECG does NOT rule out ACS—30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG. 2, 5