Chest Pain MDM

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Chest Pain NOS (Low Risk)

Given History, Exam, and Workup I have low suspicion for ACS, Pneumothorax, Pulmonary Embolus, Tamponade, Aortic Dissection or other emergent problem as a cause for this presentation.

Last Stress Test: never
Last Heart Catheterization: never
HEART Score: ***

Disposition: Discharge home with strict return precautions for worsening chest pain, shortness of breath, or new symptoms. Instructions for prompt primary care follow up and outpatient stress testing if indicated.

High Risk Chest Pain / NSTEMI

Patient at increased risk for Major Adverse Cardiac Event (AMI, PCI, CABG, death).

Last Stress Test: ***
Last Heart Catheterization: ***
HEART Score: ***

Interventions:

  • ASA 325 mg PO
  • Heparin bolus 60 u/kg (max 5,000 units)
  • Heparin gtt 12-15 u/kg/hr (max 1,000 u/hr)
  • Defer heparin drip if patient is pain-free at this time (use clinical judgment)
  • PRN analgesia with fentanyl
  • PRN antiemetic therapy

Disposition: Admit for continued cardiac monitoring, serial troponins, and further evaluation for potential inpatient stress testing vs cardiac catheterization and coronary angiography.

Unstable Angina / NSTEMI (Expected >24h to LHC/PCI)

Interventions:

  • ASA 325 mg PO
  • Enoxaparin 1 mg/kg BID

Clinical Education

HEART Score

The HEART score remains a validated and widely-used risk stratification tool in the ED for chest pain. Low scores (0-3) exclude short-term Major Adverse Cardiac Events (MACE) with greater than 98% certainty.

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS Guideline continues to support structured risk stratification for chest pain in the ED. The HEART score, when combined with high-sensitivity troponin, has been shown to increase safe ED discharges and decrease admissions without a difference in MACE outcomes.

High-Sensitivity Troponin Pathways

High-sensitivity troponin (hs-cTn) has changed the approach to serial troponin testing:

0/1 Hour Pathway (ESC recommended): Obtain hs-cTn at presentation and at 1 hour. The ESC 2020 NSTE-ACS guidelines recommend the 0/1h algorithm as the primary rapid rule-out strategy.

0/3 Hour Pathway (Traditional): For patients presenting with <6 hours of symptoms, low risk if both 0- and 3-hour troponin levels are below the 99th percentile upper reference limit.

Key data point: A 0-hour hs-cTnI <4 ng/L, or 0-hour <6 ng/L with a 2-hour delta of <5 ng/L, has a 99.9% negative predictive value for ruling out AMI.

Clinical note: Based on first troponin and clinical context, hs-cTn can be used in low-risk populations to safely avoid a second troponin draw.

Hyperacute T Waves

Hyperacute T waves are the earliest ECG sign of acute coronary occlusion, preceding ST-segment elevation. Both ACC and ESC recommend identifying hyperacute T waves as a STEMI equivalent requiring emergent reperfusion.

Example – Hyperacute T Waves (anterior leads): Image: 12-lead ECG demonstrating hyperacute T waves in V2–V4 with broad base and depressed ST takeoff. Source: Levis JT. “ECG Diagnosis: Hyperacute T Waves.” Perm J. 2015;19(3):79. PMC4500486 (CC BY) See also: LITFL T-Wave ECG Library for additional examples across all territories.

Recognition tips (per Amal Mattu):

  • Consider T waves ischemic when they are large enough to “fill” the preceding QRS complex
  • An initial slope that is linear (rather than concave upslope) suggests early ischemia even with smaller T waves
  • Compare ST segment to the following TP segment rather than the preceding PR segment

Hyperacute vs. Hyperkalemia: Hyperkalemic T waves tend to be narrow and peaked with a sharp apex, while ischemic hyperacute T waves are broad-based with increased symmetry. Clinical context (renal function, potassium level) is essential for differentiation.

Action: Obtain serial ECGs every 15–30 minutes when suspicion is present. Riley et al. (2013, Am Heart J) found that 11% of STEMIs were caught on the 2nd or later ECG, not the 1st.

2025 JACC: study published the first objective scoring definition (HATW score) for hyperacute T waves, showing they are specific for occlusion MI even without diagnostic ST elevation. (Link)

See also: Dr. Smith’s ECG Blog – 30 Examples of Hyperacute T-Waves (examples across anterior, inferior, and lateral territories)

CT PE in Pregnancy

ACOG Committee Opinion No. 723 supports that diagnostic imaging including CT should not be withheld from pregnant patients when clinically indicated. Fetal risk of anomalies, growth restriction, or abortion has not been reported with radiation exposure less than 50 mGy.

Fetal radiation doses:

Study Fetal Dose (mGy)
CT pulmonary angiogram 0.01–0.66
VQ scan 0.01–0.5
CT abdomen (low dose) ~1.4
CT abdomen (high dose) 1–25
CT pelvis (high dose) 10–50

CTPA results in lower fetal radiation exposure compared to VQ scanning.

Lead Misplacement

V6 and aVR pointing in the same direction suggests lead misplacement. When suspected, repeat the entire ECG rather than attempting to troubleshoot individual leads.

LVH with Strain Pattern

LVH with strain may produce T-wave inversion in leads I and aVL (must see in both leads to attribute to strain). This pattern can also produce ST elevation in V1–V3 that mimics anterior ischemia. See: LITFL – LVH ECG Library for visual examples of strain pattern.

References

  1. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation. 2025. Link
  2. 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain. J Am Coll Cardiol. 2021. PubMed
  3. HEART Score Validation with hs-cTn Pathway. Circ Cardiovasc Qual Outcomes. 2024. Link
  4. ESC-TROP: Effectiveness and Safety of the ESC 0h/1h Troponin Rule-Out Protocol. J Am Heart Assoc. 2024. Link
  5. Hyperacute T Waves Are Specific for Occlusion Myocardial Infarction. JACC: Advances. 2025. Link
  6. Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015;19(3):79. PMC (CC BY)
  7. Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction. Ann Emerg Med. 2022. Link
  8. Riley RF et al. Diagnostic Time Course, Treatment, and In-Hospital Outcomes for STEMI Patients. Am Heart J. 2013.
  9. ACOG Committee Opinion No. 723: Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Obstet Gynecol. 2017. Link

ECG image resources used under educational/CC licensing:

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