Initial Management of Chest Pain

Immediate Assessment and Triage

The American College of Cardiology and the European Heart Journal recommend that patients with severe, prolonged chest pain of acute onset should receive immediate hospital care, as this could indicate potentially life-threatening conditions such as heart attack, unstable angina, aortic dissection, pulmonary embolism, or pneumothorax 3, 4
A 12-lead ECG should be obtained and reviewed within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes, as recommended by the American College of Cardiology and Circulation 1, 2
Cardiac troponin should be measured as soon as possible after presentation for patients with suspected acute coronary syndrome (ACS), according to the Journal of the American College of Cardiology 2
Patients with clinical evidence of ACS or other life-threatening causes of chest pain seen in an office setting should be transported urgently to the emergency department, ideally by emergency medical services (EMS), as recommended by the Journal of the American College of Cardiology 2

The American College of Cardiology recommends obtaining a focused history including characteristics and duration of symptoms, associated features, and cardiovascular risk factor assessment 1, 5
Key elements to assess in the history include nature of pain, onset and duration, location and radiation, precipitating factors, relieving factors, and associated symptoms, as recommended by the Journal of the American College of Cardiology 5
Indicators of potentially serious conditions include interruption of normal activity and accompanying cold sweat, nausea, vomiting, fainting, or anxiety/fear, according to the European Heart Journal 4

For suspected heart attack, the European Heart Journal recommends administering fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible, and considering short-acting nitrates if there is no bradycardia or hypotension 3, 4
The Journal of the American College of Cardiology recommends monitoring vital signs and cardiac rhythm continuously for patients with suspected heart attack 2
For all patients with chest pain, Circulation recommends placing them on cardiac monitor immediately with emergency resuscitation equipment nearby, and having a defibrillator readily available 6

The Journal of the American College of Cardiology recommends that if the initial ECG is nondiagnostic but clinical suspicion for ACS remains high, serial ECGs should be performed to detect potential ischemic changes 2
Supplemental ECG leads V7-V9 are reasonable to rule out posterior myocardial infarction when initial ECG is nondiagnostic, according to the Journal of the American College of Cardiology 2
Chest radiography is useful to evaluate for other potential cardiac, pulmonary, or thoracic causes of chest pain, as recommended by the Journal of the American College of Cardiology 2

High-risk features warranting immediate attention include recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus, according to the European Heart Journal 8

The European Heart Journal notes that physical examination contributes minimally to diagnosing heart attack unless there is associated shock 3
Circulation recommends that relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia, as other conditions may show comparable response 1
The American College of Cardiology notes that there is frequently a lack of correlation between intensity of symptoms and seriousness of disease 1
Patients often delay seeking medical attention for chest pain, with longer delays in older patients and those in rural areas, according to the European Heart Journal 9, 10
Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, lightheadedness, or vague abdominal symptoms, as noted by Circulation 1

The Journal of the American College of Cardiology recommends that patients with STEMI or high-risk features should be treated according to ACS guidelines with consideration for immediate reperfusion therapy 2
Patients with non-cardiac causes of chest pain should be treated according to the specific diagnosis, as recommended by the Journal of the American College of Cardiology 5