Acute Chest Pain Management

Initial Assessment and Diagnostic Testing

The American College of Cardiology recommends that an ECG should be acquired and reviewed for STEMI within 10 minutes of arrival, and cardiac troponin should be measured as soon as possible when ACS is suspected 1, 2, 3, 4
Evaluate chest pain characteristics, including nature, onset and duration, location and radiation, severity, precipitating factors, relieving factors, and associated symptoms, as recommended by the American Heart Association 5, 6
Perform a focused cardiovascular examination to aid in diagnosis of ACS or other serious causes, as suggested by the American College of Cardiology 5, 7, 6
Look for specific findings based on suspected etiology, such as diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, mitral regurgitation murmur for ACS, as recommended by the American College of Cardiology 1, 2

A 12-lead ECG must be performed within 10 minutes of arrival, as recommended by the American College of Cardiology 1, 2, 3, 4
Cardiac troponin should be measured as soon as possible in the ED setting, as recommended by the American College of Cardiology 1, 2, 4
Chest radiography is useful to evaluate for cardiac, pulmonary, or thoracic causes, as suggested by the American College of Cardiology 7

The American College of Cardiology recommends that patients with suspected ACS or life-threatening cause should be transported urgently to the ED via EMS, without delaying transfer for troponin testing 1, 2, 3, 4, 8
If STEMI is present on ECG, treat according to STEMI guidelines, as recommended by the American College of Cardiology 3, 7
If ST depression or T-wave inversions are present, treat according to NSTE-ACS guidelines, as recommended by the American College of Cardiology 3, 7

Delayed ECG interpretation can delay critical interventions, as warned by the American College of Cardiology 1, 3, 4
Relying on nitroglycerin response is not necessarily diagnostic of myocardial ischemia, as noted by the American Heart Association 5, 6
Office-based troponin testing should not delay transfer to the ED in suspected ACS, as recommended by the American College of Cardiology 1, 2, 8