In a hemodynamically stable patient with acute chest pain and an uncertain diagnosis, what is the most appropriate initial evaluation?

• A. ECG and serial troponins, plus chest imaging as indicated
• B. Immediate coronary angiography
• C. CT angiography as first-line
• D. Observation without testing

Answer: (A)

The essential approach to acute chest pain in a stable patient starts with rapid ECG assessment and serial measurements of troponin. An ECG quickly reveals STEMI, which demands urgent reperfusion, and it also helps categorize non-ST elevations or other ECG patterns that raise concern for myocardial ischemia. Troponin is the most specific biomarker for myocardial injury, but levels can be normal at presentation, so repeating them over several hours is crucial to detect a rising or falling pattern that indicates an evolving infarction or NSTEMI.

Chest imaging is included as indicated by the clinical picture to look for alternative or contributing causes (such as pneumonia, pneumothorax, edema, or heart failure) or to assess for other thoracic conditions. In a hemodynamically stable patient, there’s no justification to proceed directly to invasive coronary angiography, and CT angiography as first-line testing isn’t warranted unless there’s a specific non-coronary diagnosis being pursued (for example, suspected aortic dissection or pulmonary embolism) or when ACS is unlikely and CTA would meaningfully change management. Observation without testing risks missing a treatable, potentially fatal cardiac event.