Management of Acute Chest Pain

Initial Assessment and Triage

The European Society of Cardiology recommends obtaining a 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 3
The European Heart Association suggests drawing blood samples for cardiac biomarkers (troponin T or I, CK-MB mass) on admission and at 10-12 hours after symptom onset 2
Assess vital signs, level of consciousness, and signs of hemodynamic instability (heart rate <40 or >100/min, systolic BP <100 or >200 mmHg, cold extremities), as recommended by the European Heart Association 4
Evaluate for high-risk features: ongoing pain, associated symptoms (sweating, nausea, vomiting), and ECG changes, according to the European Society of Cardiology 5

The European Heart Association recommends administering fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible for suspected ACS 5, 6
Provide pain relief with intravenous morphine titrated according to pain severity, even before ECG interpretation, as suggested by the European Heart Association 6
Administer sublingual or intravenous nitrates for suspected myocardial ischemia or to reduce cardiac filling pressures, unless contraindicated by hypotension or bradycardia, according to the European Heart Association 6

The European Society of Cardiology recommends initiating immediate reperfusion therapy (thrombolysis or primary PCI) within 30 minutes of diagnosis for ST-segment elevation myocardial infarction 2, 7
Transfer directly to cardiac catheterization laboratory if PCI facilities are available, as suggested by the European Heart Association 6

For suspected pulmonary embolism, the European Heart Association recommends considering pulmonary scintigraphy or spiral CT examination 7
For suspected aortic dissection, the European Society of Cardiology suggests performing transthoracic/transesophageal echocardiography, CT, or MR imaging 7

Observe patients with low-to-moderate risk for 10-12 hours after symptom onset, as recommended by the European Heart Association 2
Equip unit with resuscitation capabilities, cardiac rhythm monitoring, and ST-segment monitoring, according to the European Heart Association 1

Assess for high-risk features: recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus, as suggested by the European Society of Cardiology 3
Consider admission to coronary care unit for patients with ongoing pain, ischemic ECG changes, positive troponin, left ventricular failure, or hemodynamic abnormalities, according to the European Heart Association 2