Chest Pain Algorithm

 

Chest Pain Evaluation Algorithm – Detailed, Stepwise Clinical Approach

Chest pain is a common yet high-stakes presentation. The primary goal is rapid identification of life-threatening causes while avoiding unnecessary testing in low-risk patients. A structured algorithm improves safety, accuracy, and efficiency.

1. Immediate Triage and Stabilization (First 5–10 Minutes)

Assess ABCs and vital signs immediately. • Airway, breathing, circulation • Pulse oximetry • Blood pressure in both arms if dissection suspected • Cardiac monitor • IV access

Red flags requiring immediate resuscitation: • Hypotension or shock • Hypoxia • Altered mental status • Ongoing severe chest pain • Ventricular arrhythmias • ST-elevation on monitor

Give early supportive therapy if unstable: • Oxygen if SpO₂ < 90% • Aspirin 150–325 mg (unless contraindicated) • Nitroglycerin if ischemic pain and no hypotension • Morphine only if pain refractory and diagnosis reasonably clear

2. Rapid Identification of Life-Threatening Causes (Rule Out First)

Think of the “Deadly 6”: • Acute coronary syndrome (ACS) • Aortic dissection • Pulmonary embolism • Tension pneumothorax • Esophageal rupture • Acute pericardial tamponade

Focused questions and signs guide urgency: • Tearing pain radiating to back → dissection • Sudden dyspnea + pleuritic pain → PE • Sharp unilateral pain + absent breath sounds → pneumothorax • Chest pain relieved by leaning forward → pericarditis • Severe pain after vomiting → esophageal rupture

3. Focused History (OPQRST + Risk Stratification)

Key pain characteristics: • Onset: sudden vs gradual • Provocation: exertion, respiration, position • Quality: pressure, tearing, sharp, burning • Radiation: arm, jaw, back, interscapular • Severity: numeric scale • Time course: intermittent, progressive, persistent

Associated symptoms: • Dyspnea • Diaphoresis • Nausea/vomiting • Syncope • Palpitations • Fever or cough

Risk factor assessment: • CAD risk: age, diabetes, smoking, hypertension, dyslipidemia • Thromboembolism risk: recent surgery, immobilization, cancer • Dissection risk: hypertension, connective tissue disease, bicuspid valve • Infection or inflammatory history

4. Physical Examination (Targeted and High-Yield)

Cardiovascular: • New murmurs (acute MR, AR) • Pericardial rub • JVP elevation • Pulse deficit or BP differential

Respiratory: • Asymmetric breath sounds • Crepitations • Signs of consolidation or pneumothorax

Chest wall: • Reproducible tenderness (suggests musculoskeletal, but does not fully exclude ACS)

Peripheral signs: • DVT signs • Cyanosis • Peripheral edema

5. Initial Investigations (Within 10 Minutes)

Mandatory first-line tests: • 12-lead ECG within 10 minutes • High-sensitivity troponin (baseline) • Chest X-ray

ECG interpretation priorities: • ST elevation or new LBBB → STEMI pathway • ST depression, T-wave inversion → ischemia • Diffuse ST elevation + PR depression → pericarditis • Sinus tachycardia, S1Q3T3 → possible PE (non-specific)

6. Risk Stratification for Suspected ACS

Use validated scores after initial ECG and troponin.

HEART score components: • History • ECG • Age • Risk factors • Troponin

Interpretation: • HEART 0–3: low risk → consider early discharge • HEART 4–6: intermediate risk → observation, serial troponins • HEART ≥7: high risk → invasive evaluation

7. Serial Testing and Observation Pathway

If initial ECG and troponin are non-diagnostic: • Repeat troponin at 1–3 hours (hs-troponin protocol) • Repeat ECG if pain recurs • Continuous monitoring

Possible outcomes: • Rising troponin → NSTEMI management • Stable negative troponins → consider non-cardiac causes or stress imaging

8. Imaging Based on Clinical Suspicion

Not routine for all patients.

CT aortogram: • Suspected aortic dissection

CT pulmonary angiography: • Suspected PE with positive Wells score or D-dimer

Echocardiography: • Wall motion abnormality • Pericardial effusion • Acute valvular pathology

Stress testing or CT coronary angiography: • Low to intermediate risk stable patients

9. Non-Cardiac Chest Pain Evaluation (After Exclusion of Emergencies)

Common causes: • Gastroesophageal reflux disease • Esophageal spasm • Musculoskeletal pain • Costochondritis • Anxiety or panic disorder • Herpes zoster (early phase)

Clues favoring non-cardiac origin: • Pain reproducible on palpation • Burning retrosternal pain with meals • Pain lasting seconds or many hours without ECG changes • Normal serial troponins

10. Disposition and Documentation

Admit: • Confirmed ACS • Hemodynamic instability • High-risk features despite negative initial tests

Observe: • Intermediate-risk chest pain • Inconclusive early testing

Discharge: • Low-risk score • Negative serial ECGs and troponins • Clear follow-up plan and return precautions

Key Takeaway

Chest pain evaluation is not about ruling in a diagnosis immediately but about safely ruling out life-threatening conditions first. A structured algorithm combining rapid triage, ECG, troponins, and risk stratification ensures timely care while minimizing missed diagnoses and unnecessary admissions.