Chest pain and dyspnea triage

Scope

Use for

Initial adult office triage for chest pain/dyspnea; acute dangerous causes must be excluded before outpatient workup.

Not for

• Hemodynamic instability requiring emergency transport.
• Hospital-level acute coronary or respiratory failure management.

Immediate actions

• Record onset, vital signs, oxygen saturation, and cardiopulmonary examination; obtain a 12-lead ECG promptly if available without delaying emergency transfer.
• Ask about pressure/discomfort in the chest, arm, jaw, back, or upper abdomen and associated dyspnea, sweating, nausea, or syncope; an anginal equivalent may occur without chest pain.

Red flags: escalate now

If any of these are present, stop routine steps and follow the urgency stated. Activate emergency care for instability or findings that need immediate transfer.

• Activate EMS for suspected acute coronary syndrome, shock, severe respiratory distress/hypoxemia, concerning syncope, or suspected aortic dissection/pneumothorax; stable vital signs do not exclude these causes.
• Suspected PE needs an urgent diagnostic pathway; use ED transfer when high probability, deteriorating, or timely testing cannot be secured.

First-line plan

• Do not use a normal single ECG or office HEART calculation without troponin to exclude ACS. Acute-care pathways use ECG and serial high-sensitivity troponin as indicated.
• PERC applies only after a clinician establishes low PE probability and all criteria are negative. Otherwise follow probability-based D-dimer/imaging; high probability requires imaging, not D-dimer exclusion. Use a pregnancy-specific pathway when applicable.
• Reserve outpatient workup for stable presentations after dangerous acute causes have been assessed; document the working diagnosis, testing access, and disposition rationale.

Follow-up and monitoring

• Assign responsibility and a time for reviewing outstanding tests and unresolved symptoms.
• Give explicit 911 instructions for recurrent rest pain, collapse, severe breathlessness, or deterioration; routine referral must not delay urgent assessment.

Before the patient leaves

Return precautions you can say as written:

“If symptoms get worse, new warning signs appear, or you cannot follow the plan from this visit, seek urgent care now.”

• Point to the red flags above that apply to this patient.
• Confirm follow-up timing and where to go after hours.
• Attach a relevant handout to reinforce the plan.
• Document disposition, rationale, unresolved uncertainty, and that precautions were understood.

About this workflow

Clinical owner

Family Medicine Editorial Team

Risk tier

High

Review cadence

Every 3 months

Last reviewed

September 4, 2026AI-assisted evidence review. Clinical-owner sign-off is not recorded for this update.

Review status

Evidence current. Next review due December 4, 2026.

References

• AHA/ACC 2021 chest pain guideline (opens in a new tab)
• Thrombosis Canada Pulmonary embolism diagnosis (April 2025) (opens in a new tab)