From the Guidelines
The emergency department workup for left-sided chest pain radiating to the back with onset four days ago should prioritize immediate ECG and troponin measurement to rule out acute coronary syndrome and other life-threatening conditions. Initial assessment includes vital signs, oxygen saturation, and a focused history to characterize the pain and associated symptoms. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, an ECG should be obtained and interpreted within 10 minutes of arrival to evaluate for acute coronary syndrome, particularly ST-elevation myocardial infarction (STEMI), as early recognition improves outcomes.
Key components of the workup include:
- Immediate ECG to evaluate for STEMI or other acute coronary syndromes
- Troponin measurement as it is the most sensitive test for diagnosing acute myocardial injury, as stated in the guideline 1
- Complete blood count, basic metabolic panel, and coagulation studies as important baseline tests
- Chest radiography to identify pulmonary pathology
- Consideration of a CT angiogram of the chest with contrast to evaluate for aortic dissection, pulmonary embolism, and other thoracic pathologies, especially if the ECG and initial biomarkers do not reveal a clear cardiac cause
- Additional tests such as D-dimer if pulmonary embolism is suspected and echocardiography if a cardiac etiology is considered
Pain management with appropriate analgesics should be provided based on severity, ensuring that it does not mask symptoms that could lead to a diagnosis. The comprehensive approach is necessary because the described pain pattern could indicate several serious conditions, including acute coronary syndrome, aortic dissection, pulmonary embolism, or musculoskeletal issues, and the four-day duration does not exclude life-threatening pathology, emphasizing the need for prompt and thorough evaluation as recommended by the guideline 1.
From the Research
Emergency Department Workup for Chest Pain
The emergency department workup for left side of chest pain radiating to the back that started four days ago involves a comprehensive evaluation to rule out life-threatening conditions such as acute coronary syndrome (ACS) 2, 3, 4.
- Initial Assessment: The initial assessment includes a thorough history, physical examination, electrocardiogram (ECG), and serial troponin assays to evaluate patients with suspected ACS 3, 5.
- Risk Stratification: Risk stratification scores such as the TIMI and GRACE scores have been validated for patients with known ACS, but may have limitations in undifferentiated chest pain patients 2, 3.
- Imaging Modalities: Advancements in imaging modalities such as coronary computed tomography angiography and CT-derived fractional flow reserve have demonstrated utility in evaluating patients presenting with acute chest pain 3.
- Clinical Gestalt: The ED physician's overall assessment of ACS likelihood, including the chest pain history, ECG, and initial troponin result, is crucial in determining the diagnostic value of the workup 5.
- Further Evaluation: If the initial workup is equivocal, further evaluation with stress testing or coronary computed tomography angiography can be used in the emergency department to rule out acute myocardial ischemia 4.
- Alternative Diagnoses: It is essential to consider alternative diagnoses, such as aortic aneurysm or pulmonary embolism, in patients with chest pain and elevated troponin levels 6.