Chest Pain: Clinical Approach and Treatment

1. Life-Threatening Causes to Rule Out First ("The Big Five")

• Goldman-Cecil Medicine emphasizes: "New, acute, often ongoing pain may indicate an acute myocardial infarction, unstable angina, or aortic dissection; a pulmonary cause, such as acute pulmonary embolism or pleural irritation; a musculoskeletal condition of the chest wall, thorax, or shoulder; or a gastrointestinal abnormality."

2. Initial Evaluation (All Patients)

1. IV access + cardiac monitoring immediately
2. 12-lead ECG within 5–10 minutes of arrival (critical for STEMI identification)
3. Vitals including bilateral arm blood pressures (unequal → dissection)
4. Chest X-ray (widened mediastinum, pneumothorax, pulmonary edema)
5. Labs: Troponin, BNP/NT-proBNP, CBC, BMP, D-dimer (if PE suspected), coagulation panel
6. Oxygen if SpO₂ < 90%

3. Treatment by Cause

A. Acute Coronary Syndrome (ACS: STEMI / NSTEMI / Unstable Angina)

• STEMI: Primary PCI is preferred; target door-to-balloon ≤90 min. Fibrinolysis (e.g., alteplase) if PCI unavailable within 120 min.
  • 4 Ds: Door → Data (ECG) → Decision → Drug/device
• NSTEMI/UA: Risk-stratify (TIMI/GRACE score); early invasive strategy (PCI within 24–72h) for high-risk patients.

Key: "Signs of successful reperfusion include chest pain relief, 50% reduction in ST-segment elevation, and idioventricular rhythm." — Washington Manual of Medical Therapeutics

B. Aortic Dissection

• Type A (ascending) → Emergency surgical repair
• Type B (descending) → Medical management first: IV β-blocker (labetalol, esmolol) to reduce heart rate <60 bpm and SBP 100–120 mmHg; then vasodilators (nitroprusside) if needed
• Avoid thrombolytics and anticoagulation
• Confirm with CT angiography, TEE, or MRI

C. Pulmonary Embolism

• Anticoagulation: UFH (if high-risk/unstable) or LMWH/DOAC (rivaroxaban, apixaban) for submassive/low-risk
• Massive PE (hemodynamic instability): Systemic thrombolysis (alteplase 100 mg IV) or catheter-directed thrombolysis/thrombectomy
• Supportive: Oxygen, vasopressors if shocked

D. Tension Pneumothorax

• Immediate needle decompression: 2nd intercostal space, midclavicular line
• Follow with tube thoracostomy (chest drain)

E. Cardiac Tamponade

• Pericardiocentesis (needle aspiration of pericardial fluid) — definitive
• IV fluids temporarily to maintain preload; avoid diuretics/nitrates

F. Pericarditis

• NSAIDs (ibuprofen 600 mg TID or aspirin 750–1000 mg TID) + colchicine 0.5 mg BID for 3 months — reduces recurrence by ~50%
• Restrict strenuous activity
• Avoid anticoagulants if effusion is large

G. Musculoskeletal / Costochondritis

• NSAIDs (ibuprofen, naproxen)
• Local heat, activity modification
• Point tenderness on palpation is a helpful diagnostic clue

H. Gastroesophageal Reflux Disease (GERD) / Noncardiac Chest Pain

• PPI therapy (omeprazole, pantoprazole) — first-line and often diagnostic
• If esophageal motility disorder (spasm): nitrates, calcium channel blockers (diltiazem), smooth muscle relaxants
• Antidepressants (amitriptyline, citalopram) for functional/visceral hypersensitivity chest pain — Yamada's Gastroenterology
• H. pylori eradication if peptic ulcer disease confirmed

I. Pleuritis / Pleurisy

• Treat the underlying cause (infection, autoimmune, PE)
• NSAIDs for pain
• Intercostal nerve block for refractory cases

4. Disposition

Key Clinical Pearls

• Aspirin should not be withheld if ACS is suspected — administer before the ECG if needed. However, hold aspirin if aortic dissection cannot be excluded, as it increases bleeding risk perioperatively.
• IV morphine does not reduce ACS mortality and may worsen outcomes — use cautiously and only for refractory pain.
• Right-sided MI requires careful fluid management — nitroglycerin can be fatal by reducing preload.
• Patients without classic chest pain (women, elderly, diabetics) have double the in-hospital mortality from AMI due to diagnostic and treatment delays — Tintinalli's Emergency Medicine.

Note: This is a clinical overview. Real patient management must integrate patient-specific factors, local protocols, and specialist guidance.