Can’t Miss Diagnoses
- Acute Coronary Syndrome
- Aortic Dissection
- Pericardial tamponade
- Pulmonary Embolism
- 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
Risk-stratify chest pain patients into low, moderate, and high-risk groups with the help of HEART SCORE for MACE .
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
- May need 15 lead ECG
- Review right ventricular infarction
- 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
- First 5 min: Approach to: Chest pain
- CRACKCast E026 – Chest Pain
- EMCases: Low-Risk Chest Pain and High Sensitivity Troponin
- CRACKCast E085 – Aortic Dissection
- CRACKCast E076 – Pneumonia