What is the diagnostic workup for chest pain (thoracic pain)?

From the Guidelines

The workup for chest pain should begin with a thorough history and physical examination to determine the likelihood of life-threatening causes, and high-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The initial evaluation should focus on identifying patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, as these patients will benefit the most from cardiac imaging and testing 1.

Key Components of the Workup

• A thorough history and physical examination to determine the likelihood of life-threatening causes such as acute coronary syndrome, pulmonary embolism, aortic dissection, or pneumothorax
• Initial testing should include an electrocardiogram (ECG) to evaluate for ST-segment changes or arrhythmias, and cardiac biomarkers (high-sensitivity troponin) to assess for myocardial injury 1
• Chest X-ray to examine cardiac silhouette and lung fields, and basic laboratory tests including complete blood count, basic metabolic panel, and coagulation studies
• For patients with suspected acute coronary syndrome, serial troponin measurements at 0,3, and 6 hours are recommended 1

Additional Testing

• Stress testing (exercise or pharmacologic with imaging) for intermediate-risk patients
• Coronary CT angiography for intermediate-risk patients, or invasive coronary angiography for high-risk patients or those with positive non-invasive tests 1
• For suspected pulmonary embolism, D-dimer testing followed by CT pulmonary angiography is appropriate
• Patients with concerning symptoms such as tearing pain radiating to the back should undergo CT angiography of the chest to evaluate for aortic dissection
• Point-of-care ultrasound can rapidly identify pericardial effusion or pneumothorax in unstable patients

Symptom Management

• Patients should receive appropriate symptom management with medications such as nitroglycerin 0.4 mg sublingually every 5 minutes for up to 3 doses for suspected angina
• Continuous cardiac monitoring and ensuring intravenous access in case emergency interventions become necessary The evaluation and diagnosis of chest pain should be guided by clinical decision pathways, and patients should be included in decision-making, with information about risk of adverse events, radiation exposure, costs, and alternative options provided to facilitate the discussion 1.

From the Research

Initial Evaluation of Chest Pain

• Chest pain is a common presentation that requires careful diagnostic assessment due to its diverse and potentially serious causes 2
• The essential chest pain-related issues are the missed diagnoses of acute coronary syndromes with a poor short-term prognosis and the increasing percentage of hospitalizations of low-risk cases 2
• Symptoms most predictive of acute coronary syndrome (ACS) include chest discomfort that is substernal or spreading to the arms or jaw 3
• Chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS 3

Diagnostic Tests

• Electrocardiography (ECG) should be performed immediately (within 10 minutes of presentation) to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 4
• ECG interpretation is an essential part of the initial evaluation of patients with symptoms suspected to be related to myocardial ischemia, along with focused history and physical examination 5
• High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 4

Management of Acute Coronary Syndrome

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 6
• Addition of a second antiplatelet (ie, dual antiplatelet therapy) is also recommended for most patients 6
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 6
• For patients with STEMI, coronary catheterization and percutaneous coronary intervention (PCI) within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI 4
• For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death 4