Acute Chest Pain Workup

Acute chest pain is a symptom, not a diagnosis. The first task is to determine whether myocardial ischemia, another immediately fatal process, or a lower-risk cause is most likely while stabilization, testing, and consultation proceed in parallel. Describe the symptom as cardiac, possibly cardiac, or noncardiac. Avoid “atypical chest pain.” That label is imprecise: women and older adults may have ischemia with nausea, dyspnea, palpitations, fatigue, or less dramatic chest discomfort, and the label can falsely lower urgency. Pressure, tightness, squeezing, heaviness, or burning in the chest, particularly with exertion or autonomic symptoms, should keep acute coronary syndrome (ACS) high in the differential. The workup has two simultaneous aims: 1. Identify acute myocardial ischemia or infarction quickly enough to restore coronary perfusion. 2. Exclude non-coronary emergencies that a negative troponin cannot rule out, including acute aortic syndrome, pulmonary embolism (PE), tension pneumothorax, esophageal rupture, and pericarditis with tamponade. A reassuring appearance does not settle the diagnosis. A patient can have a nondiagnostic first ECG, an initially negative troponin, and a life-threatening evolving illness.