How should I manage intermittent chest pain?

Immediate Evaluation and Management of Intermittent Chest Pain

Call emergency medical services immediately and proceed to the emergency department for a 12-lead ECG within 10 minutes and high-sensitivity troponin measurement, because intermittent chest pain can represent unstable angina or early acute coronary syndrome that requires urgent evaluation even when symptoms are not currently present. 1, 2

Why Intermittent Pain Requires Urgent Evaluation

• Intermittent chest pain lasting days or occurring on multiple separate occasions qualifies as an acute presentation that mandates urgent cardiac evaluation, because this pattern may represent unstable or crescendo angina signaling imminent myocardial infarction. 1, 3
• Approximately 30–40% of acute myocardial infarctions present with a normal initial ECG, so the absence of pain at the moment of evaluation does not exclude life-threatening disease. 1
• Severe prolonged chest pain of acute onset requires immediate hospital care regardless of cause, encompassing myocardial infarction, aortic dissection, pulmonary embolism, pneumothorax, and other life-threatening conditions. 4, 2

Immediate Actions (First 10 Minutes)

• Obtain a 12-lead electrocardiogram within 10 minutes to detect ST-elevation myocardial infarction (≥1 mm in contiguous leads), ST-depression, T-wave inversions, or pericarditis patterns. 1
• Draw high-sensitivity cardiac troponin immediately on arrival; it is the most sensitive and specific biomarker for myocardial injury. 1
• Measure vital signs in both arms (heart rate, blood pressure, respiratory rate, oxygen saturation); a systolic blood-pressure difference >20 mm Hg between arms suggests aortic dissection. 1
• Perform a focused cardiovascular examination for diaphoresis, tachypnea, pulmonary crackles, S3 gallop, new murmurs, pericardial friction rub, unilateral absent breath sounds, pulse differentials, and jugular venous distension. 1

Pre-Hospital Management

• Activate EMS immediately rather than driving yourself; approximately 1.5% of chest-pain patients experience cardiac arrest during transport by personal vehicle. 1
• Chew aspirin 162–325 mg while awaiting EMS unless you have a known allergy or active gastrointestinal bleeding. 1, 3
• Sublingual nitroglycerin may be given unless systolic blood pressure is <90 mm Hg or heart rate is <50 or >100 bpm. 4, 5

Key Clinical Features to Report

High-Risk Symptoms (Require Immediate ED Evaluation)

• Pain that interrupts normal daily activities or is accompanied by cold sweats, nausea, vomiting, fainting, or anxiety/fear. 4, 2
• Retrosternal pressure, squeezing, or heaviness that builds over minutes and may radiate to the left arm, jaw, neck, or between the shoulder blades. 1
• Associated dyspnea, diaphoresis, nausea, light-headedness, presyncope, or syncope markedly increase the likelihood of acute coronary syndrome. 1
• Sudden "ripping" or "tearing" chest or back pain maximal at onset suggests aortic dissection. 1
• Sudden dyspnea with pleuritic chest pain that worsens on inspiration indicates possible pulmonary embolism. 1

Features Suggesting (But Not Excluding) Non-Cardiac Causes

• Pain that varies with respiration, body position, or food intake, is well-localized on the chest wall, or is reproduced by palpation. 4, 3
• Sharp, pleuritic pain that worsens when lying supine and improves sitting forward suggests pericarditis, yet 13% of patients with pleuritic features still have acute myocardial ischemia. 1

Serial Testing When Initial Workup Is Normal

• Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours) because a single normal result does not exclude acute coronary syndrome. 1
• Obtain serial ECGs every 15–30 minutes if clinical suspicion remains high to capture evolving ischemic changes. 1
• Add posterior leads V7–V9 when suspicion for ACS is intermediate-to-high and the standard 12-lead ECG is nondiagnostic. 1

Management Based on Initial Findings

If STEMI Is Identified

• Activate STEMI protocol immediately; target door-to-balloon time <90 minutes for primary PCI or door-to-needle time <30 minutes for fibrinolysis. 1

If ST-Depression, T-Wave Inversions, or Elevated Troponin Without ST-Elevation

• Admit to coronary care unit, start dual antiplatelet therapy (aspirin + P2Y12 inhibitor) and anticoagulation, and arrange urgent coronary angiography. 1

If Initial ECG and Troponin Are Normal

• Observe in a chest-pain unit for 10–12 hours with continuous cardiac monitoring and repeat troponin at 6–12 hours after symptom onset. 1
• If both troponin results are normal and symptoms are stable, proceed to outpatient stress testing or coronary CT angiography within 72 hours. 1

Special Population Considerations

• Women are at higher risk for underdiagnosis and more frequently present with jaw/neck pain, nausea, fatigue, dyspnea, epigastric discomfort, or back pain rather than classic chest pressure. 1
• Older adults (≥75 years) may present atypically with isolated dyspnea, syncope, delirium, or unexplained falls without classic chest pain. 1
• Patients with diabetes are more likely to present with vague abdominal symptoms, confusion, or isolated dyspnea and have a higher risk for silent ischemia. 1

Critical Pitfalls to Avoid

• Do not assume intermittent pain is benign; unstable angina can progress to acute coronary syndrome, and chronicity does not equal safety. 3
• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac pain; esophageal spasm may also respond. 1
• Do not delay EMS transport for troponin testing in office or outpatient settings when ACS is suspected. 1, 3
• Avoid the term "atypical chest pain"; describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1
• A normal physical examination does not exclude ACS; uncomplicated myocardial infarction can present with entirely normal findings. 1
• A normal initial ECG does not rule out ACS; 30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG. 1

Office-Based Decision Algorithm

• If an ECG cannot be obtained and interpreted within 10 minutes in the office, immediately transfer the patient to the ED by EMS; personal automobile transport should be avoided. 3
• If ECG shows ST-elevation, new ST-depression, or new left bundle branch block, administer aspirin 250–500 mg immediately and arrange immediate EMS transfer for STEMI/NSTE-ACS protocol. 3
• Physical examination contributes almost nothing to diagnosing myocardial infarction unless shock is present; do not rely on examination alone. 3, 2