Rapid evaluation of life-threatening causes of acute chest pain, primarily acute coronary syndrome, using ECG, troponin, and imaging.
Indication
- New-onset chest pain described as pressure, tightness, or burning
- Pain radiating to the arm, jaw, or back
- Pain that worsens with exertion and improves with rest (angina)
- Sudden, tearing-type pain radiating to the back (suspected aortic dissection)
- Pain accompanied by shortness of breath, sweating, or nausea
- Pleuritic pain (worsened by deep breathing)
- Chest pain in a person with known heart disease or risk factors
Preparation
- The patient is calmed and rests in a sitting or semi-reclined position
- Call 112 (or local emergency number); during transport, sublingual nitroglycerin may be taken if previously prescribed
- Known medications and recent doses are noted
- If there is no aspirin allergy, 300 mg aspirin may be chewed under physician/EMS guidance
How it's performed
- A 12-lead ECG is obtained within 10 minutes of arriving at the emergency department
- Cardiac enzyme (high-sensitivity troponin) serial measurements (at 0 and 1-3 hours) are performed
- If acute ST-elevation myocardial infarction (STEMI) is detected, primary PCI or thrombolytic therapy is planned within 90 minutes
- If pulmonary embolism is suspected, D-dimer and, if needed, pulmonary CT angiography are ordered
- If aortic dissection is suspected, urgent thoracic CT angiography is performed
- Non-cardiac causes (pericarditis, pneumothorax, esophageal, musculoskeletal) are evaluated through clinical and imaging findings
Post-procedure
- If acute coronary syndrome is confirmed, admission to the cardiac care unit (CCU) is arranged
- Low-risk cases may be discharged after 6-12 hours of observation and negative troponin
- In stable patients, exercise stress testing, echocardiography, or coronary CT angiography is planned
- Treatment is started for risk factors (smoking, hypertension, cholesterol, diabetes)
- Medications such as aspirin, statin, and beta-blocker are arranged if needed
Risks
- Expansion of the heart attack and permanent heart failure due to delayed diagnosis
- Fatal bleeding if aortic dissection is missed
- Radiation and contrast reactions during diagnostic procedures
- Unnecessary intervention due to false positive test results
- Risk of arrhythmia and sudden death in the first hours of disease
FAQ
Is every chest pain a heart attack?
No. Chest pain may also originate from muscles, gastric reflux, anxiety, or the lungs. However, the distinction is made by a physician through clinical examination and ECG; do not assess risk on your own at home.
If the ECG is normal, does it mean there is no heart attack?
No. The first ECG can be normal; therefore, serial ECGs and troponin measurements are performed. If suspicion persists, 24-hour observation is recommended.
For chest pain, should I call 112 or go to the emergency department on my own?
112 is recommended. ECG, oxygen, and, if needed, early treatment are possible in the ambulance. Driving alone is not safe.
Are heart attack symptoms different in women?
Yes. In women, atypical symptoms such as shortness of breath, fatigue, back-jaw pain, and nausea are more common, and recognition may be delayed.
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