How should a patient with chest pain and stable vital signs be evaluated and managed?

Evaluation and Management of Chest Pain with Stable Vital Signs

Obtain a 12-lead ECG within 10 minutes of presentation and measure cardiac troponin immediately, even when vital signs are stable, because life-threatening conditions like acute coronary syndrome, aortic dissection, and pulmonary embolism can present with normal hemodynamics. 1

Immediate Assessment (First 10 Minutes)

Mandatory Initial Actions

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

• Measure high-sensitivity cardiac troponin immediately when acute coronary syndrome is suspected; this is the most sensitive and specific biomarker for myocardial injury. 1, 2

• Assess vital signs promptly including heart rate, blood pressure in both arms (to detect pulse differentials suggesting aortic dissection), respiratory rate, and oxygen saturation. 2, 3

• Perform a focused cardiovascular examination looking for diaphoresis, tachypnea, 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

Critical History Elements to Document

• Pain characteristics: Pressure, squeezing, gripping, heaviness, or tightness suggests ischemia; sharp, stabbing, fleeting pain is less likely ischemic but does not exclude it (13% of ACS patients present with pleuritic pain). 2, 4

• Radiation pattern: Pain radiating to the left arm, neck, jaw, or between shoulder blades increases likelihood of cardiac origin; sudden "ripping" or "tearing" pain radiating to the back suggests aortic dissection. 2

• Temporal features: Anginal pain builds gradually over several minutes, not instantaneously; document exact duration relative to presentation. 2

• Positional factors: Pain that improves sitting forward and worsens supine is pathognomonic for pericarditis. 4

• Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, lightheadedness, presyncope, or syncope markedly increase probability of ACS. 2

• Cardiovascular risk factors: Age, sex, diabetes, hypertension, hyperlipidemia, smoking, and family history of premature coronary artery disease. 2

Life-Threatening Diagnoses to Exclude

Acute Coronary Syndrome (ACS)

• Typical presentation: Retrosternal pressure, squeezing, or heaviness that builds over minutes, often radiating to left arm, neck, or jaw, with associated diaphoresis, dyspnea, or nausea. 1, 2

• Physical findings may be completely normal in uncomplicated myocardial infarction; absence of abnormal findings does not exclude ACS. 2

• If initial ECG is nondiagnostic but clinical suspicion remains high: Obtain serial ECGs every 15–30 minutes and consider posterior leads V7–V9 to detect evolving ischemic changes. 1, 2

• Serial troponin testing: Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours) after initial sample to improve diagnostic accuracy. 2

• STEMI management: Activate STEMI protocol immediately; aim for primary PCI with door-to-balloon <90 minutes or fibrinolysis with door-to-needle <30 minutes. 2

• NSTE-ACS management: Admit to coronary care unit, continuous cardiac monitoring, dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation, and plan urgent coronary angiography. 2

Acute Aortic Dissection

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

• Physical clues: Pulse differential between extremities (≈30% of cases), systolic blood pressure difference >20 mmHg between arms, new aortic regurgitation murmur (40–75% of type A dissections). 2

• Management: Withhold antithrombotic therapy (aspirin, heparin) if dissection is suspected; transfer immediately to a center with 24/7 aortic imaging and cardiac surgery capability. 2

Pulmonary Embolism (PE)

• Presentation: Sudden dyspnea with pleuritic chest pain that worsens on inspiration; tachycardia and tachypnea present in >90% of patients. 1, 2, 4

• Risk stratification: Apply Wells criteria to estimate pretest probability; in low-to-intermediate probability patients, obtain age- and sex-adjusted D-dimer—a negative result effectively rules out PE. 2, 4

• Imaging: Proceed directly to CT pulmonary angiography when clinical suspicion is high or D-dimer is positive. 2, 4

Tension Pneumothorax

• Classic triad: Dyspnea, pleuritic pain on inspiration, and unilateral absent breath sounds with hyperresonant percussion; may also have tracheal deviation and hypotension. 2, 4

Acute Pericarditis

• Presentation: Sharp, pleuritic chest pain that improves when sitting forward and worsens supine. 1, 2, 4

• Physical findings: Pericardial friction rub (biphasic sound indicating pleural inflammation). 4

• ECG hallmark: Diffuse concave ST-elevation with PR-segment depression. 2, 4

• Diagnostic criteria: Pleuritic chest pain plus at least one of: pericardial friction rub, ECG changes (PR depression or diffuse ST-elevation), or new/enlarging pericardial effusion on echocardiography. 4

• Management: High-dose aspirin (500 mg–1 g every 6–8 hours) plus colchicine (0.5–0.6 mg once or twice daily for approximately 3 months); avoid glucocorticoids and non-aspirin NSAIDs as they may increase risk of recurrent MI. 4

Cardiac Tamponade

• Presentation: Pleuritic chest pain worsening supine, jugular venous distension, signs of cardiogenic shock (HR >130 or <40 bpm, SBP <90 mmHg), respiratory distress (RR >25, SpO₂ <90%), low-voltage ECG or electrical alternans. 2

Risk Stratification After Initial Assessment

High-Risk Features Mandating Immediate Admission

• Ongoing rest pain >20 minutes 2
• Hemodynamic instability (SBP <100 mmHg, HR >100 or <50 bpm) 2, 3
• Severe continuing pain with ischemic ECG changes 2
• Troponin above the 99th percentile 2
• Evidence of left-ventricular failure (crackles, S3 gallop, new murmurs) 2

Intermediate-Risk Features

• Age >70 years (or ≥75 years with dyspnea, syncope, delirium, or falls) 2
• Prior history of myocardial infarction or coronary artery disease 2
• Traditional cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD) 2

Low-Risk Criteria for Observation or Early Discharge

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

Special Population Considerations

Women

• Higher risk of underdiagnosis; more likely to present with accompanying symptoms rather than classic chest pain: jaw/neck pain (≈10% vs ≈4% in men), nausea/vomiting (≈32% vs ≈23%), epigastric discomfort, palpitations, inter-scapular pain (≈61.9% vs ≈54.8%), dyspnea, and fatigue. 2

• Use sex-specific high-sensitivity troponin thresholds (>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; women typically present 8–10 years older than men (median ≈69 vs ≈62 years). 2

Older Adults (≥75 Years)

• May present atypically with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain. 1, 2

Patients with Diabetes

• More likely to present with atypical symptoms including vague abdominal symptoms, confusion, or isolated dyspnea; higher risk for silent ischemia. 2

Setting-Specific Recommendations

Office/Outpatient Setting

• If an ECG cannot be obtained on site: Refer the patient to the emergency department immediately for ECG acquisition. 1

• When clinical evidence of ACS or another life-threatening cause exists: Arrange urgent EMS transport; do not postpone transfer for troponin or other diagnostics—delayed transfer can be detrimental. 1

• Transfer by EMS is mandatory because EMS can perform prehospital ECG (facilitating reperfusion if STEMI is present), administer aspirin, provide defibrillation, manage arrhythmias en route, and reduce travel time. 1, 2

Emergency Department

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

• Engage in shared decision-making with clinically stable patients regarding testing options, considering radiation exposure and cost. 1

Common Pitfalls to Avoid

• 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 dismiss chest pain in women, older adults, or patients with diabetes based on atypical presentations; these groups frequently lack classic symptoms. 2

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

• A normal initial ECG does not rule out ACS; 30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG, and ≈5% of ACS patients have a normal ECG. 2

• Do not delay EMS transport for troponin testing in office or outpatient settings when ACS or another life-threatening cause is suspected. 1, 2

• Avoid the term "atypical chest pain"; instead describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 2

• Do not assume reproducible chest wall tenderness excludes serious pathology; 7% of patients with palpable tenderness have acute coronary syndrome. 2, 4

• Sharp, pleuritic pain does not exclude ACS; 13% of ACS patients present with pleuritic-type chest pain. 2, 4

• Do not assume young age excludes ACS; it can occur in adolescents without traditional risk factors. 2

Alternative Diagnoses After Excluding Life-Threatening Causes

• Costochondritis/Tietze syndrome: Tenderness of costochondral joints reproducible on palpation. 2, 4, 5

• Gastroesophageal reflux disease (GERD): Burning retrosternal pain, acid regurgitation, sour or bitter taste in mouth, often postprandial. 5

• Pneumonia: Localized pleuritic pain, fever, productive cough, regional dullness to percussion, egophony, possible friction rub. 4

• Herpes zoster: Pain in dermatomal distribution triggered by touch, characteristic unilateral dermatomal rash. 4

• Myocarditis: Fever, chest pain, heart failure signs, S3 gallop. 4