EKG Evaluation in Patients with Chest Pain and Associated Symptoms

Rationale for ECG

The American College of Cardiology recommends an electrocardiogram (ECG) for all patients presenting with chest pain and associated symptoms like fever, nausea, vomiting, and headache, unless a clear non-cardiac cause is evident 1, 2
The combination of chest pain with fever, nausea, vomiting, and headache could represent several serious conditions including acute coronary syndrome (ACS), myocarditis, or pericarditis, all of which require ECG evaluation 1, 3
According to the 2021 AHA/ACC guidelines, an ECG should be performed for all patients with chest pain unless a non-cardiac cause is clearly evident 1, 2

The presence of fever specifically raises concern for conditions like myocarditis or pericarditis, which can present with ECG changes and require prompt diagnosis 3
Pericarditis typically presents with fever, pleuritic chest pain that increases in supine position, and characteristic ECG changes 1, 3
When chest pain is accompanied by nausea and vomiting, these symptoms can be present in ACS, particularly in women, older adults, and patients with diabetes 2

The ECG should be acquired and interpreted within 10 minutes of patient arrival to any medical facility 2, 3
If the initial ECG is non-diagnostic but clinical suspicion for ACS remains high, serial ECGs should be performed, especially if symptoms persist or worsen 4, 5
Cardiac biomarkers (particularly troponin) should be measured in patients with suspected ACS 2, 3

Attributing chest pain solely to fever or gastrointestinal symptoms without obtaining an ECG 2, 3
Relying on a single normal ECG to rule out ACS when clinical suspicion is high 5