Emergency Department Evaluation and Management of Chest Pain
Immediate Actions (First 10 Minutes)
Obtain a 12-lead ECG within 10 minutes of arrival and draw a high-sensitivity cardiac troponin immediately to identify life-threatening conditions including acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, cardiac tamponade, and esophageal rupture. 1, 2
Mandatory Initial Testing
- Interpret the ECG immediately for ST-elevation ≥1 mm in contiguous leads (STEMI), ST-depression, T-wave inversions, or diffuse ST-elevation with PR-depression (pericarditis). 1, 2
- Measure high-sensitivity cardiac troponin on arrival—it is the most sensitive and specific biomarker for myocardial injury, superior to CK or CK-MB. 1, 2, 3
- Record vital signs in both arms (heart rate, blood pressure, respiratory rate, oxygen saturation) to detect pulse differentials or systolic BP differences >20 mmHg suggesting aortic dissection. 2
- Perform a focused cardiovascular examination for diaphoresis, tachypnea, tachycardia, hypotension, pulmonary crackles, S3 gallop, new murmurs, pericardial friction rub, unilateral absent breath sounds, pulse differentials, and jugular venous distension. 1, 2
Life-Threatening Diagnoses to Exclude
Acute Coronary Syndrome (ACS)
- Typical presentation: Retrosternal pressure, squeezing, or heaviness that builds gradually over minutes (not instantaneous), often radiating to the left arm, neck, jaw, or between shoulder blades. 1, 2, 3
- Associated symptoms that markedly increase probability: Dyspnea, diaphoresis, nausea, vomiting, lightheadedness, presyncope, or syncope. 1, 2, 3
- Critical caveat: 30–40% of acute myocardial infarctions present with a normal or nondiagnostic initial ECG; a normal ECG does not exclude ACS. 2, 4
- Sharp or pleuritic pain does not rule out ACS: Approximately 13% of patients with pleuritic chest pain have acute myocardial ischemia. 2, 3
Acute Aortic Dissection
- Presentation: Sudden, maximal-onset "ripping" or "tearing" chest or back pain radiating to the upper or lower back. 1, 2
- Physical clues: Pulse differential between extremities (~30% of cases), systolic BP difference >20 mmHg between arms, new aortic regurgitation murmur (40–75% of type A dissections). 2
- Critical action: Withhold aspirin, heparin, and all antithrombotic therapy if dissection is suspected; arrange immediate transfer to a facility with 24/7 aortic imaging (CT/MRI/TEE) and cardiac surgery capability. 2, 4
Pulmonary Embolism (PE)
- Presentation: Sudden dyspnea with pleuritic chest pain that worsens on inspiration; tachycardia present in >90% of patients. 1, 2, 4
- Risk factors: Oral contraceptive use, recent surgery, immobilization, malignancy. 2
- Diagnostic approach: Apply Wells criteria; obtain age- and sex-adjusted D-dimer for low-to-intermediate probability, or proceed directly to CT pulmonary angiography if high probability. 2
Tension Pneumothorax
- Presentation: Dyspnea and sharp chest pain worsening on inspiration. 2
- Physical findings: Unilateral absent or markedly reduced breath sounds, hyperresonant percussion, tracheal deviation, hypotension. 2, 5, 6
Cardiac Tamponade
- Presentation: Pleuritic chest pain worsening when supine. 2
- Physical findings: 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, 6
Esophageal Rupture (Boerhaave Syndrome)
- Presentation: Severe substernal pain after forceful vomiting; subcutaneous emphysema and pneumothorax in ~20% of cases. 2, 5, 6
Serial Testing When Initial Workup Is Nondiagnostic
- 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, 4
- Obtain serial ECGs every 15–30 minutes if clinical suspicion remains high to capture evolving ischemic changes. 2, 4
- Add posterior leads V7–V9 when suspicion for ACS is intermediate-to-high and the standard ECG is nondiagnostic. 2, 4
Management Algorithms Based on Initial Findings
STEMI Identified (ST-elevation ≥1 mm in contiguous leads)
Activate STEMI protocol immediately: Target door-to-balloon time <90 minutes for primary PCI (preferred) or door-to-needle time <30 minutes for fibrinolysis. 2, 3, 4
NSTE-ACS (ST-depression, T-wave inversions, or elevated troponin without ST-elevation)
Admit to coronary care unit with continuous cardiac monitoring, initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor) and anticoagulation, and plan urgent coronary angiography. 2, 4
High-Risk Features Requiring Immediate CCU Admission
- Ongoing rest pain >20 minutes with ischemic ECG changes. 2, 4
- Hemodynamic instability (SBP <100 mmHg, HR >100 or <50 bpm). 2
- Troponin above the 99th percentile. 2, 4
- Evidence of left-ventricular failure (crackles, S3 gallop, new murmurs). 2, 4
Low-Risk Patients (Normal ECG, Negative Troponin at Presentation and 6–12 Hours, Stable Vitals)
Observe in a chest-pain unit for 10–12 hours or discharge for outpatient stress testing within 72 hours. 2, 4, 7
Pre-Hospital and EMS Management
- Activate EMS immediately for any suspected life-threatening chest pain; do not transport by personal vehicle (1.5% risk of cardiac arrest en route). 1, 2
- Administer chewed aspirin 162–325 mg unless contraindicated by known allergy or active gastrointestinal bleeding. 1, 2, 3
- Give sublingual nitroglycerin unless systolic BP <90 mmHg or HR <50 or >100 bpm. 2
- Provide IV morphine 4–8 mg (repeat 2 mg every 5 minutes as needed) for pain relief, recognizing that pain increases sympathetic drive and myocardial workload. 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
Special Populations
Women
- Higher risk of underdiagnosis: Women more frequently present with jaw/neck pain, nausea, fatigue, dyspnea, epigastric discomfort, or back pain rather than classic chest pressure. 1, 2, 3
- Use sex-specific troponin thresholds: >16 ng/L for women vs >34 ng/L for men; universal cutoffs miss ~30% of women with STEMI. 2
Older Adults (≥75 Years)
- Atypical presentations: Isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain. 1, 2, 4
Young Patients (<40 Years)
- Do not assume young age excludes ACS: Acute coronary syndrome can occur even in adolescents without traditional risk factors. 3
- Sharp or pleuritic pain does not exclude ACS: 22% of patients with sharp/stabbing pain and 13% with pleuritic features had acute myocardial ischemia. 3
Critical Pitfalls to Avoid
- Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain; esophageal spasm and other conditions may also improve. 2, 3
- Do not delay EMS transport for troponin testing in office or outpatient settings when ACS is suspected. 1, 2, 3
- Avoid the term "atypical chest pain"; instead describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1, 2, 3
- A normal physical examination does not exclude ACS; uncomplicated myocardial infarction can present with entirely unremarkable findings. 1, 2
- A normal initial ECG does not rule out ACS; 30–40% of acute MIs present with a normal or nondiagnostic ECG. 2, 4
Office/Outpatient Setting Recommendations
- If an ECG cannot be obtained on site: Refer the patient to the emergency department immediately for ECG acquisition. 2
- When clinical evidence of ACS or another life-threatening cause exists: Arrange urgent EMS transport; do not postpone transfer for troponin or other diagnostics. 2, 3
Chest-Pain Observation Unit Requirements
- Essential equipment: Full resuscitation capability, continuous cardiac rhythm and blood-pressure monitoring, continuous ST-segment surveillance, and automated arrhythmia alarms. 4, 7
- Staffing: Experienced physicians and nurses trained in rapid diagnostic work-up and early therapeutic interventions. 4
- Observation duration: Typically 10–12 hours of monitored care for non-high-risk patients. 2, 4, 7