Chest pain is understandably one of the most frequent reasons that people present to an emergency department (ED). While it is a common symptom, it can potentially be the sign of a severe condition, and thus warrants a time-sensitive evaluation. For this reason, we want to take the time to explain the standard diagnostic approach to chest pain, and what to expect during and after your ED visit.
When someone is having chest pain, the first and most important test is an EKG. This is an electrical tracing of your heartbeat that can be obtained quickly and gives us some critical information within minutes of the patient’s arrival. Most importantly, it will rule out an acute heart attack (when there is a blockage in one a coronary arteries, preventing the heart muscle from getting the blood and oxygen it needs to pump normally). While it may take some time for a patient to make their way through triage, the waiting room, and into a treatment room, their EKG is brought immediately to a doctor to screen for any cardiac emergencies. The EKG also tells us if you have an arrhythmia (when your heart beats too fast, too slow, or in an abnormal rhythm), or signs of structural heart disease (an enlarged heart, for example), however both of these conditions are typically less emergent than a heart attack.
Given most patients who come into the ED with chest pain are not having a heart attack, several other tests are sometimes initiated from the triage room to evaluate for other causes of chest pain while the patient awaits a treatment room to become available. This sometimes includes laboratory tests, more specifically blood counts, electrolyte levels, kidney and liver function tests, and a blood test commonly referred to as a ‘troponin’ or ‘cardiac enzyme.’ This is a protein that is elevated in the blood whenever there is significant physiologic stress or strain on the heart; it is not specific to a particular disease or condition but provides a general screening tool for a heart condition. We also sometimes obtain an Xray of the chest, which also allows us to evaluate for conditions such as fluids in the lungs, a collapsed lung, pneumonia, an enlarged heart (which can be a sign of heart failure), to name just a few examples.
It is common that our testing in the ED does not show any concerning abnormalities or apparent cause for the patient’s symptoms. In this scenario, the physician may be able to make a clinical diagnosis based on the characteristics of a patient’s symptoms alone. Commonly, however, no clear diagnosis can be made in the ED. This can be understandably frustrating to the patient, but we do our best first to rule out an acute life-threatening process, and then allow for the appropriate amount of time and subsequent testing to make the right diagnosis in the end. An EKG, for example, rules out a heart attack, but it does not rule out coronary artery disease (when there are narrowed areas in the heart’s arteries that can ultimately lead to a heart attack). In the absence of a clear diagnosis, the physician will either recommend a more extended stay in the hospital to run more tests (such as a CT scan of the chest to look for a blood clot, or a stress test to look for coronary artery disease), or determine a patient is safe to be discharged and follow up with a doctor for further evaluation and testing as an outpatient. These decisions are always made with careful consideration to a particular patient’s circumstances, and often in consultation with on-call cardiologists, internal medicine doctors, and a patient’s primary care doctor.
This means that oftentimes the ED is often the first stop, but not the last, in the evaluation of a patient’s chest pain. After we rule out a life-threatening condition, our next goal is to help a patient figure out the most appropriate next step in their evaluation process. As is true for many symptoms, it often requires several rounds of testing and doctor’s appointments, and time, to make the right diagnosis. Most importantly, however, we want patients to understand that because an ED visit cannot always entirely exclude cardiac chest pain, they should not await their next outpatient appointment if their chest pain (or associated symptoms) are getting worse. In this scenario, repeat ED evaluations are often necessary to assess for any change in their EKG or blood tests, and sometimes hospitalization to expedite their cardiac testing.