← Diagnosis and Management Guides
Chest Pain Risk Stratification
Key considerations: ACS, Aortic dissection, PE
Cannot miss
- ACS
- Aortic dissection
- PE
- Tension pneumothorax
Likely diagnoses
- Musculoskeletal
- GERD
- Anxiety
- Costochondritis
- Pericarditis
Red flags
- Exertional chest pressure
- Radiation to jaw/arm
- Diaphoresis
- New ECG changes
- Positive troponin
Workup
- history: OPQRST, cardiac risk factors, prior workup; exam: Vital signs, cardiac and pulmonary exam, reproducible chest wall tenderness; labs: ECG, troponin (high-sensitivity serial 0/1 or 0/3hr); BMP, CBC; imaging: CXR; bedside: 12-lead ECG within 10 minutes
Management
- immediate: ECG within 10 minutes, STEMI activation if applicable; general: Risk stratify with HEART score; HEART 0-3 + negative hsTn: <1% 30-day MACE — safe for discharge; HEART 4-6: observation, serial troponins, consider stress testing; HEART ≥7: high risk — admit, cardiology consult
Disposition
- admit: HEART ≥7, positive troponin, dynamic ECG changes; discharge: HEART 0-3 with negative serial troponins, normal ECG, low clinical suspicion; consults: Cardiology for positive troponin or high-risk features
Clinical pearls
- HEART score 0-3 with negative high-sensitivity troponin at 0 and 3 hours has <1% 30-day MACE rate — one of the safest discharge decisions in EM
- The 0/1 hour high-sensitivity troponin protocol can safely rule out MI in 60 minutes
Source and review
- ESC Chest Pain Guidelines 2024. Last reviewed: 2024-11-01