Chest Pain

Key considerations: Acute Coronary Syndrome (ACS), Aortic Dissection, Pulmonary Embolism

Cannot miss

history: Onset, provocation, quality, radiation, severity, timing (OPQRST); Prior cardiac history, stents, CABG; Risk factors: HTN, DM, hyperlipidemia, smoking, family hx premature CAD; Cocaine or stimulant use; Recent immobilization, surgery, travel (PE risk); Pleuritic vs positional vs exertional character; exam: Vital signs including bilateral BP (dissection); Cardiac: murmurs, rubs, S3/S4, JVD; Pulmonary: equal breath sounds, crackles, wheezes; Chest wall: reproducible tenderness (costochondritis); Vascular: pulse deficits, unequal BPs; Abdominal: epigastric tenderness (GI causes); labs: Troponin (high-sensitivity preferred) — serial at 0 and 3 hours; CBC, BMP, magnesium; D-dimer (if PE on differential and low pretest probability); BNP/NT-proBNP if heart failure suspected; Lipase if epigastric component; Coagulation studies if anticoagulated; imaging: CXR: pneumothorax, widened mediastinum, pulmonary edema, rib fractures; CT Angiography chest if dissection or PE suspected; Echocardiogram: wall motion abnormalities, effusion, tamponade; CT Coronary Angiography in low-intermediate risk if available; bedside: 12-lead ECG within 10 minutes of arrival — repeat if symptoms change; Point-of-care ultrasound: pericardial effusion, RV dilation (PE), pneumothorax, wall motion; Compare to prior ECG if available

immediate: 12-lead ECG within 10 minutes; IV access, cardiac monitor, continuous pulse oximetry; Aspirin 324mg chewed if ACS suspected (unless contraindicated); Nitroglycerin 0.4mg SL q5min x3 for ischemic pain (hold if SBP <90 or RV infarct); general: Serial troponins at 0 and 3 hours (high-sensitivity protocol); Risk stratify using HEART score; Pain management — avoid IM injections if considering anticoagulation; Continuous telemetry monitoring; specific: diagnosis: STEMI; steps: Activate cath lab immediately — door-to-balloon <90 min; Aspirin 324mg + P2Y12 inhibitor (ticagrelor 180mg or clopidogrel 600mg); Heparin bolus per protocol; Avoid fibrinolytics if PCI available within 120 min; diagnosis: NSTEMI / Unstable Angina; steps: Aspirin + anticoagulation (heparin or enoxaparin); Cardiology consult for risk stratification; Beta-blocker if no contraindications; Admit to monitored bed; diagnosis: Aortic Dissection; steps: Target HR <60 and SBP <120 — esmolol or labetalol drip; Emergent CT angiography; Type A (ascending): emergent cardiac surgery; Type B: medical management, ICU admission; diagnosis: Pulmonary Embolism; steps: Anticoagulation with heparin; Massive PE with hemodynamic instability: systemic tPA; Submassive PE: consider catheter-directed therapy; See PE diagnosis entry for full workup

admit: STEMI, NSTEMI — cath lab / CCU / monitored bed; Positive or rising troponin; HEART score ≥7 (high risk); Hemodynamic instability; Aortic dissection or PE confirmed; New arrhythmia; discharge: HEART score 0–3 with negative serial troponins; Clear alternative diagnosis (MSK, GERD); Normal ECG, normal troponins, low risk; Reliable follow-up within 72 hours; consults: Cardiology: ACS, new arrhythmia, positive troponin; Cardiac surgery: Type A aortic dissection; Pulmonology/IR: massive or submassive PE

A normal ECG does not rule out ACS — 6% of STEMI patients have initially normal ECGs
Right-sided ECG (V4R) if inferior STEMI to evaluate for RV involvement — avoid nitrates and volume deplete if RV infarct
HEART score 0–3 with negative high-sensitivity troponin has <1% 30-day MACE rate
Young women, diabetics, and elderly may present atypically — have a low threshold for workup
Cocaine chest pain: benzodiazepines + nitroglycerin. Avoid beta-blockers (unopposed alpha stimulation)

ACC/AHA STEMI Guidelines 2013, AHA/ACC NSTE-ACS Guidelines 2014, ESC Chest Pain Guidelines 2024. Last reviewed: 2024-11-01