Pitfalls in evaluating the low-risk chest pain patient

Risk stratification and management of the patient with low-risk chest pain continues to be challenging despite the considerable effort of numerous investigators. Evidence exists that a specific subset of young patients can be defined as low risk in whom further testing may not be necessary. A high index of suspicion of acute coronary syndrome (ACS) and an understanding of the many, subtle, and atypical presentations of ischemic heart disease are required. The initial history, electrocardiogram (ECG), and biomarkers are important, but serial ECGs and biomarkers improve sensitivity in detecting ACS. Unless chest pain is clearly explained, objective testing, such as exercise treadmill testing, nuclear scintigraphy, stress echocardiography, or coronary computed tomography angiogram, should be considered before, or soon after, discharge.