Initial Workup for Shortness of Breath with Mild/Moderate Chest Pain

Immediate Assessment (Within 10 Minutes)

Obtain a 12-lead ECG within 10 minutes of presentation to evaluate for ST-segment changes, new Q waves, T-wave inversions, or new left bundle branch block, as recommended by the American College of Cardiology and the European Heart Journal 1, 3
Compare with previous ECG if available, particularly valuable in patients with pre-existing cardiac pathology such as left ventricular hypertrophy, according to the European Heart Journal 4, 2
Initiate continuous multi-lead ECG monitoring for arrhythmias and ST-segment changes, as suggested by the European Heart Journal 4, 2
Document specific chest pain characteristics: nature, onset and duration, location and radiation, precipitating factors, relieving factors, and associated symptoms, as recommended by the American College of Cardiology and the journal Circulation 1, 3
Sharp chest pain that increases with inspiration and lying supine is unlikely ischemic and suggests pericarditis, according to the American College of Cardiology 1
Assess cardiovascular risk factors including age, diabetes, prior myocardial infarction, and angina history, which increase probability of acute cardiac ischemia, as recommended by the American College of Cardiology 1

Perform focused cardiovascular examination specifically evaluating for valvular heart disease, hypertrophic cardiomyopathy, heart failure signs, and pulmonary disease, as suggested by the European Heart Journal and the journal Circulation 4, 2, 3

Draw cardiac troponin T or I immediately on admission as the preferred marker of myocardial damage, according to the European Heart Journal 4, 2
Repeat troponin measurement at 10-12 hours after symptom onset for diagnosis of possible myocardial infarction and risk assessment, as recommended by the European Heart Journal 4, 2, 5
Elevated troponin identifies high-risk patients requiring aggressive management, according to the European Heart Journal 4, 2
Measure hemoglobin to detect anemia as a potential contributor, as suggested by the European Heart Journal 4, 2

Obtain chest radiograph as initial imaging study for all patients with dyspnea and chest pain, as recommended by the Journal of the American College of Radiology and the European Heart Journal 6, 5
Evaluate for pulmonary venous congestion, cardiomegaly, pneumonia, pneumothorax, and pleural effusion, according to the Journal of the American College of Radiology and the European Heart Journal 6

Recurrent ischemia, elevated troponin levels, and hemodynamic instability during the 8-12 hour observation period are high-risk features requiring aggressive management, as suggested by the European Heart Journal 4, 2
Administer aspirin 250-500 mg as soon as possible, initiate heparin, give beta-blocker unless contraindicated, and provide oral or intravenous nitrates for persistent or recurrent symptoms, as recommended by the European Heart Journal 4, 2, 5

Pneumothorax presents with acute chest pain and dyspnea, according to the European Heart Journal 5
Acute pericarditis is characterized by sharp pain increased with inspiration and lying supine, as suggested by the American College of Cardiology 1
Aortic dissection is characterized by sudden onset ripping chest pain with radiation to back, evaluate for pulse differential, according to the American College of Cardiology 1

Atypical presentations are common, particularly in older patients, women, and those with diabetes, as noted by the journal Circulation and the European Heart Journal 3
Five-day duration of symptoms does not exclude acute coronary syndrome, as unstable angina can present with prolonged or recurrent symptoms, according to the European Heart Journal 4, 2