In an adult with intermittent chest pain, neutrophilic leukocytosis, blurred vision, and non‑alcoholic fatty liver disease, what is the most urgent diagnostic and therapeutic priority?

Urgent Evaluation of Chest Pain with Neutrophilic Leukocytosis

The most urgent priority is to exclude acute coronary syndrome (ACS) by obtaining a 12-lead ECG within 10 minutes and drawing a high-sensitivity cardiac troponin immediately, followed by urgent transfer to the emergency department via EMS if either test is abnormal. 1

Immediate Life-Threatening Conditions to Rule Out

The combination of intermittent chest pain with neutrophilic leukocytosis raises concern for several urgent diagnoses that must be excluded within the first 10 minutes:

• Acute coronary syndrome is the highest priority given the chest pain presentation; neutrophilia can accompany acute myocardial infarction as part of the inflammatory response 1, 2
• Acute pericarditis presents with chest pain and can cause leukocytosis; look for sharp pleuritic pain that worsens supine and improves leaning forward, plus fever and a friction rub 1
• Pulmonary embolism causes sudden dyspnea with pleuritic chest pain and is associated with leukocytosis; tachycardia occurs in >90% of cases 1

Mandatory First 10 Minutes

• Obtain a 12-lead ECG within 10 minutes to detect STEMI (≥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 because it is the most sensitive and specific biomarker for myocardial injury 1, 2
• Measure vital signs promptly including heart rate, bilateral blood pressures, respiratory rate, and oxygen saturation 1
• Perform focused cardiovascular examination for diaphoresis, tachypnea, pulmonary crackles, S3 gallop, new murmurs, pericardial friction rub, or unilateral absent breath sounds 1

Critical History Elements for Chest Pain

• Pain quality: Pressure, squeezing, gripping, heaviness, or tightness increases the probability of ischemia; sharp, stabbing pain suggests pericarditis but does not exclude ACS (13% of patients with pleuritic pain have acute MI) 1
• Radiation pattern: Pain radiating to the left arm, neck, jaw, or between shoulder blades supports cardiac origin 1
• Temporal pattern: Anginal pain builds gradually over several minutes, not instantaneously 1
• Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, or light-headedness markedly increase ACS likelihood 1, 2

Interpretation of Initial Results

If ECG Shows Ischemic Changes or Troponin is Elevated

• Activate EMS immediately and arrange urgent transfer to a facility with 24/7 cardiac catheterization capability 1, 2
• STEMI management: Target door-to-balloon time <90 minutes for primary PCI or door-to-needle <30 minutes for fibrinolysis 1
• NSTE-ACS management: Admit to coronary care unit with continuous cardiac monitoring, initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation, and plan urgent coronary angiography 1, 3

If Initial ECG and Troponin Are Normal

• Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours) because a single normal result does not exclude ACS 1, 2
• Obtain serial ECGs every 15–30 minutes if clinical suspicion remains high to capture evolving ischemic changes 1, 2
• Consider posterior leads (V7–V9) when suspicion is intermediate-to-high and the standard ECG is nondiagnostic 1

Addressing the Neutrophilic Leukocytosis

While the chest pain takes priority, the elevated white blood cell count with increased neutrophils requires consideration of:

• Inflammatory cardiac conditions: Acute pericarditis or myocarditis can cause both chest pain and leukocytosis 1
• Acute MI-associated inflammation: Neutrophilia commonly accompanies myocardial infarction as part of the acute inflammatory response 1
• Concurrent infection: Pneumonia can present with chest pain and leukocytosis; assess for fever, productive cough, and focal lung findings 1

Blurred Vision Considerations

The blurred vision requires urgent ophthalmologic evaluation after cardiac causes are excluded, as it may indicate:

• Hypertensive emergency: Check blood pressure in both arms; pulse or pressure differentials may suggest aortic dissection 1
• Diabetic complications: Given the fatty liver, assess for undiagnosed diabetes with point-of-care glucose 2
• Embolic phenomena: If ACS is confirmed, consider embolic events from cardiac thrombus 1

Fatty Liver Context

Non-alcoholic fatty liver disease is associated with:

• Increased cardiovascular risk: NAFLD patients have higher rates of coronary artery disease, making ACS more likely in this population 4, 5
• Hypercoagulability: NAFLD is associated with a prothrombotic state that increases risk of both arterial and venous thrombosis 4
• Metabolic syndrome: The presence of fatty liver suggests underlying insulin resistance, diabetes, dyslipidemia, and hypertension—all major ACS risk factors 5, 6

Critical Pitfalls to Avoid

• Do not delay EMS transport for additional testing when ACS is suspected; immediate transfer is essential 1, 2
• Do not assume a normal physical examination excludes ACS; uncomplicated myocardial infarction can present with entirely normal findings 1
• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain; esophageal spasm may also improve 1
• A normal initial ECG does not rule out ACS; 30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG 1, 3

Disposition Algorithm

1. Abnormal ECG or elevated troponin → Immediate EMS transfer to cardiac catheterization center 1, 2
2. Normal initial tests but high clinical suspicion → Admit to monitored unit for serial troponins and continuous cardiac monitoring 1, 2
3. Low-risk after serial testing → Observe in chest-pain unit for 10–12 hours or discharge for outpatient stress testing within 72 hours 1