Clinical Scenario
Undifferentiated chest pain
VIGNETTE
- A 58-year-old presents to AMU with central chest pain since the morning.
- Comorbidities: hypertension, smoker.
- Obs: HR 92, BP 148/86, SpO2 97%, afebrile.
INITIAL APPROACH
A–E assessment, IV access, 12-lead ECG within 10 minutes, continuous cardiac monitoring, aspirin 300 mg PO if ACS suspected, oxygen only if SpO2 <94%.
DIFFERENTIAL (LIFE-THREATENING FIRST)
- ACS, aortic dissection, PE, tension pneumothorax, oesophageal rupture, pericarditis/tamponade.
- Then GORD, MSK and anxiety.
FOCUSED HISTORY & EXAM
- SOCRATES, cardiovascular risk factors, leg swelling, syncope, tearing/inter-scapular radiation (dissection), pleuritic/positional change. Compare BP in both arms
- auscultate for new murmurs or rub
- assess JVP and bilateral air entry.
INVESTIGATIONS
- Bedside: ECG, troponin (0 and 3 h), CXR, ABG if hypoxic.
- Bloods: FBC, U&E, LFT, D-dimer (only if PE plausible after Wells), glucose.
- Imaging: CTPA or CT aorta when red flags present.
- Echo if haemodynamically unstable.
MANAGEMENT BY DIAGNOSIS
- - STEMI → PPCI pathway, dual antiplatelets, anticoagulation, statin. - NSTEMI → GRACE risk-stratify, fondaparinux, ticagrelor, angio within 72 h. - Dissection → BP control with labetalol (target SBP 100–120), urgent cardiothoracics. - PE → anticoagulate
- thrombolyse if massive.
ESCALATION & PITFALLS
- Early consultant and cardiology liaison for any troponin rise or dynamic ECG.
- Common pitfalls: anchoring on MSK pain, missing a normal ECG dissection, and forgetting right-sided/posterior leads.