CanadiEM Frontline Primer

CanadiEM Frontline Primer – Chest Pain

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Can’t Miss Diagnoses

  • Acute Coronary Syndrome
  • Aortic Dissection
  • Pericardial tamponade
  • Pulmonary Embolism
  • Pericarditis
  • Pneumonia
  • Tension pneumothorax
  • Esophageal rupture

Points to focus upon

  • Risk factors for Coronary Artery Disease and Pulmonary Embolism
  • Functional Status – Exercise Tolerance, Recent Decline?
  • Use of Medications – Nitro Spray effective? Adherent to anticoagulant prescriptions?
  • Habits to inquire about – Smoking, Recent or recurrent cocaine use
  • Hemoptysis, Dyspnea (symptoms consistent with PE)
  • Always check for signs of DVT on your physical exam.


  • CBC, BUN, Cr, Lytes, Glucose,
  • Serial Troponin (usually 2-3 hours apart)
  • Serial ECGs (especially if recurrent chest pain)
  • Chest x-ray where warranted
  • Consider D-Dimer where appropriate (use PERC to rule out)
  • ECG – Remember to compare an old ECG; Consider 15-lead ECG if pain refers to back
  • Consider telemetry
Tips on Tests

hs-troponin T – the 2h delta to rule-out is <4ng/L and the delta to rule-in is >= 10ng/L. ( EM CASES)
CXR – looking for alternative diagnoses (Pneumothorax, pneumonia) or incidental findings (ground-glass opacities, suggestive of COVID-19)

Clinical Decision Tools of Relevance


Pulmonary Embolism


Risk Stratification

Risk-stratify chest pain patients into low, moderate, and high-risk groups with the help of HEART SCORE for MACE .

Low-Risk Patients

May qualify for early discharge using HEART Pathway

Low-risk patients with a follow-up troponin (at 3 hours) can be considered for safe discharge home with appropriate follow-up.

Other Management Pearls

  • Hypotensive patients with inferior wall ST changes
  • Assess pts with focal neuro signs for aortic dissection
  • <93% O2, consider oxygen supplementation and monitoring, Aspirin where warranted
  • Remember, we usually do serial Troponins and ECG where warranted. Guidelines advise that these troponins should be at least 2 hours apart. Consult your institutional policy for specific guidance based on your troponin assay.

“One ECG begets another” – Dr. Amal Mattu

Recommended reading, videos, and podcasts

The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.

This post was edited by Dr. Brent Thoma MD FRCPC. This post was copyedited and uploaded by Evan Formosa.

Afsheen Mehar

Dr. Afsheen Mehar is a resident physician at the University of Toronto in the RCPSC Emergency Medicine Training Program. Her greatest passions are medical education, POCUS and austere medicine. She holds an RDMS certification in ultrasound.

Teresa Chan

Senior Editor at CanadiEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Chief Strategy Officer of CanadiEM. Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University.