At the Bedside

Start with an immediate instability screen: airway, breathing, circulation, vitals, mental status, and whether the patient looks ill, diaphoretic, hypotensive, or hypoxic. Get a focused pain history: onset, provocation, quality, radiation, severity, exertional component, pleuritic vs positional features, associated dyspnea/syncope/diaphoresis/nausea, and relevant risks like CAD, cocaine use, pregnancy/postpartum state, VTE history, connective tissue disease, recent surgery/immobility, and aortic disease.

Do a fast but targeted exam:
  • General appearance, perfusion, pulse symmetry, BP in both arms if concern for dissection
  • Cardiac exam for new murmur, muffled heart sounds, friction rub
  • Lungs for unilateral breath sounds, wheeze, crackles
  • Chest wall tenderness does not exclude serious disease
  • Legs for edema/DVT signs
  • Abdominal exam if concern for referred pain or dissection extension
Initial tests in most patients:
  • ECG within 10 minutes
  • Serial troponins using your institution’s high-sensitivity pathway
  • CXR for pneumothorax, widened mediastinum, pneumonia, effusion, edema
  • Point-of-care ultrasound when available: pericardial effusion/tamponade, RV strain, pneumothorax, gross LV function, aortic root clues
  • Labs as indicated: CBC, CMP, BNP, D-dimer only if pretest probability supports it, pregnancy test in anyone who could be pregnant
Use a structured risk approach:
  • ACS concern: ischemic chest pressure, exertional symptoms, diaphoresis, nausea, radiation, ECG changes, troponin rise
  • Aortic dissection concern: abrupt maximal pain, tearing/ripping quality, pulse deficit, neuro deficit, new AR murmur, mediastinal widening
  • PE concern: pleuritic pain, tachycardia, hypoxia, hemoptysis, VTE risk, signs of DVT
  • Pericarditis/myopericarditis: pleuritic/positional pain, relief leaning forward, diffuse ST elevation/PR depression
  • Pneumothorax: sudden pleuritic pain/dyspnea, unilateral decreased breath sounds, POCUS confirmation
  • Esophageal rupture: severe pain after vomiting/retching, subcutaneous emphysema, mediastinal air
  • GI causes: epigastric/RUQ pain, pancreatitis, biliary disease, perforation
Initial treatment depends on suspected etiology:
  • If ACS is possible: aspirin unless contraindicated, nitrates if not hypotensive/RV infarct/PDE5 use, analgesia as needed, anticoagulation/activation if STEMI or high-risk ACS
  • If dissection is suspected: pain control and rapid BP/HR reduction before/while obtaining definitive imaging; avoid reflex anticoagulation until excluded
  • If PE likely: anticoagulate if no contraindication and imaging delay is substantial/diagnosis is high probability
  • If pneumothorax/tension physiology: immediate decompression
  • If pericardial tamponade: urgent pericardiocentesis/supportive care
  • If esophageal rupture: NPO, broad-spectrum antibiotics, emergent surgical consult
Disposition is risk driven:
  • Admit/observe for serial troponins, ECGs, and provocative testing or cardiology workup if ACS cannot be safely excluded
  • CTA chest/aorta for dissection or PE based on pretest probability
  • Discharge only if a clearly low-risk syndrome is identified and serious causes are adequately excluded, with strict return precautions and follow-up
A Classic Presentation
A 58-year-old man with diabetes and hyperlipidemia comes in with 45 minutes of central pressure-like chest pain radiating to the left arm, associated with diaphoresis and nausea. He looks uncomfortable and mildly pale, but is not hypotensive; ECG shows subtle anterior ST depression with dynamic T-wave changes, and initial high-sensitivity troponin is normal. He gets aspirin, nitroglycerin with improvement, serial ECG/troponins, and cardiology evaluation for suspected NSTE-ACS.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 58-year-old man with diabetes, hypertension, and hyperlipidemia presenting with 1 hour of substernal pressure that started at rest and radiates to the left arm. My main concern is acute coronary syndrome because the pain is typical, exertional symptoms are absent but the quality and associated diaphoresis/nausea are worrisome, and he has multiple CAD risk factors. On exam he’s uncomfortable but hemodynamically stable, without focal lung findings or a pulse deficit. ECG shows nonspecific ST-T changes without STEMI, and the first troponin is negative, so this is not ruled out yet. I’m less concerned for dissection or PE right now because he doesn’t have abrupt tearing pain, neuro deficits, hypoxia, or pleuritic features. I’ve given aspirin, started nitroglycerin as tolerated, and I’m planning serial ECGs/troponins with observation and cardiology involvement if biomarkers or symptoms evolve.

Study Directive

  • Build a 10-minute chest pain algorithm from memory: unstable vs stable, ischemic vs non-ischemic, cardiac vs pulmonary vs vascular vs GI.
  • Practice reading 20 ECGs for chest pain patterns: STEMI, posterior MI, diffuse ischemia, pericarditis, RV strain, hyperkalemia mimics.
  • Draw a one-page “don’t anticoagulate until excluded” list for dissection mimics.
  • Review your shop’s high-sensitivity troponin pathway and know exact serial timing.

Recent Literature