Acute Chest Pain Evaluation

Initial Assessment

The American Heart Association recommends obtaining a 12-lead ECG within 10 minutes of presentation to quickly identify potential life-threatening conditions, and characterizing chest discomfort, including heaviness, pressure, tightness, and squeezing, is crucial for diagnosis 1
Chest radiography is recommended to evaluate for aortic pathology, pneumothorax, and pneumonia, with guidance from the American College of Radiology and the American College of Cardiology 1, 2
A thorough history should be obtained from patients, including specific behaviors observed during episodes, and determining if the patient can localize pain with one finger, which may indicate a musculoskeletal cause, as recommended by the American Heart Association and the American College of Cardiology 3, 4

Diagnostic Testing

Serial troponin testing at 0, 3, and 6 hours is recommended for patients with suspected acute coronary syndrome, as per the American Heart Association guidelines 1
CT angiography of the chest may be considered if there is suspicion for aortic dissection or pulmonary embolism, based on recommendations from the Journal of the American College of Radiology 2
The following diagnostic tests are recommended for Acute Coronary Syndrome (ACS):

Specific Conditions

Acute coronary syndrome may present with atypical symptoms in women, despite a lack of traditional risk factors, and chest heaviness for 6 hours is concerning for ongoing ischemia, according to the American Heart Association 1
Acute aortic syndrome, including dissection and intramural hematoma, is characterized by pain radiating to the back, and sudden onset of pain that migrates from chest to back is highly suspicious, as per the American Heart Association guidelines 1
Pulmonary embolism can present with chest discomfort, although it is less likely without shortness of breath, and cannot be excluded based on symptoms alone, as recommended by the American College of Chest Physicians 1
Certain populations, including women, elderly patients, and diabetic patients, are more likely to present with atypical symptoms, such as unusual fatigue, sleep disturbances, shortness of breath, indigestion, anxiety, generalized weakness, confusion, stroke-like symptoms, syncope, or changes in mental status, with a strength of evidence rated as moderate 11, 12, 13

Management

If ST-segment elevation is present, immediate reperfusion therapy (primary PCI preferred) should be initiated, and if PCI is not available within 120 minutes, consider fibrinolysis, as recommended by the European Society of Cardiology and the American College of Cardiology, with a strength of evidence rated as high 6, 7
If no ST-segment elevation but high-risk features are present, antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation with heparin (unfractionated or LMWH), and early invasive strategy (coronary angiography within 24 hours) should be considered, with a strength of evidence rated as moderate 7, 14
For confirmed Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS), beta-blockers, statins, ACE inhibitors/ARBs should be administered, as recommended by the American College of Cardiology and the European Society of Cardiology, with a strength of evidence rated as high 5
For low-risk patients, consider non-invasive testing (stress test, coronary CT), with a strength of evidence rated as low 15
The American Heart Association recommends calling 9-1-1 immediately for emergency medical services transport if ACS is suspected, with aspirin administration of 162-325mg to be chewed while awaiting EMS, and the European Heart Society recommends aspirin 250-500mg chewed, supplemental oxygen if saturation <90%, IV access, continuous cardiac monitoring, and pain relief with nitrates and opioids if needed for all suspected ACS patients, with a strength of evidence rated as high 13, 16, 7, 17, 8