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Emergency
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Chest Pain in the Emergency Department
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ECG + CXR + cardiac markers, with hemodynamics first.
Decision
Outcome
Decision
ED chest pain. First steps?
✓
Focused H&P, vitals, IV access
✗
Stress test
Decision
Hemodynamic status?
✓
Stable → ECG + CXR + ASA (if dissection unlikely)
✓
Unstable → stabilize, search for cause
Decision
ECG consistent with ACS?
✓
STEMI → emergent PCI / thrombolytics
✓
NSTEMI/UA → anticoagulation + antiplatelet + risk stratification
✓
Non-ischemic ECG → evaluate other causes (PE, pericarditis, dissection, esoph rupture)
Outcome
Emergent cath lab activation
Outcome
DAPT + anticoagulation; risk stratify (TIMI/GRACE); early invasive vs ischemia-guided
Troponin trend over 0/3 or 0/1 h.
Outcome
PE workup (Wells → D-dimer/CTPA), pericarditis (ECG, echo, NSAIDs + colchicine), aortic dissection (CTA/TEE), Boerhaave
Outcome
Stabilize hemodynamics, treat underlying cause (cardiogenic shock, tamponade, tension PTX, massive PE)
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