Evaluation and Management of Epigastric Chest Discomfort

Initial Assessment and Investigations

The European Society of Cardiology recommends obtaining vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, to assess hemodynamic stability 1, 2
The American College of Cardiology suggests performing a focused cardiovascular examination to identify potentially serious causes of chest pain and complications 2
Evaluate for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or murmurs, which may indicate acute coronary syndrome (ACS), as recommended by the American College of Cardiology 2
Assess for epigastric tenderness, which may suggest gastrointestinal causes, such as esophagitis or peptic ulcer disease, according to the American College of Cardiology 2
Obtain a 12-lead ECG within 10 minutes of presentation to evaluate for STEMI or other acute cardiac conditions, as recommended by the American College of Cardiology 2, 3
Draw blood for cardiac troponin measurement as soon as possible to assess for myocardial injury, according to the American College of Cardiology 2, 3

Acute coronary syndrome (ACS) must be ruled out first, despite gastrointestinal symptoms, as recommended by the European Society of Cardiology 1 and the American College of Cardiology 3
Consider acute aortic syndrome, especially if pain is described as severe or "ripping" with radiation to the back, according to the American College of Cardiology 5
Pulmonary embolism should be considered, particularly if associated with dyspnea or tachycardia, as recommended by the American College of Cardiology 2
High-risk features requiring immediate attention include interruption of normal activity by symptoms, presence of cold sweat, nausea, vomiting, or anxiety, abnormal ECG changes suggestive of ischemia, elevated cardiac troponin levels, and hemodynamic instability or signs of heart failure, according to the European Society of Cardiology 1 and the American College of Cardiology 2, 3

If ACS is suspected, administer aspirin 325 mg immediately and consider nitroglycerin if no contraindications, as recommended by the European Society of Cardiology 4 and the American College of Cardiology 3
Arrange urgent transfer to the emergency department if not already there, according to the American College of Cardiology 3, 4
If a gastrointestinal cause is suspected after cardiac causes are ruled out, consider proton pump inhibitor or H2 blocker for acid-related disorders, as recommended by the European Society of Cardiology 4
If pulmonary embolism is suspected, consider D-dimer testing and appropriate imaging (CT pulmonary angiogram), according to the American College of Cardiology 2 and the European Society of Cardiology 4

If initial cardiac evaluation is negative but symptoms persist, consider stress testing (exercise or pharmacologic) to evaluate for inducible ischemia, as recommended by the American College of Cardiology 2, 3
Upper endoscopy may be considered if a gastrointestinal cause is suspected, according to the European Society of Gastroenterology 6
CT chest with contrast may be considered if aortic pathology remains a concern, as recommended by the American College of Cardiology 5