What is the appropriate management for a patient presenting with chest pain?

From the Guidelines

When a patient presents with chest pain, the first step should be to acquire and review an ECG within 10 minutes of arrival to rule out ST-segment–elevation myocardial infarction (STEMI) 1. This approach is crucial in identifying life-threatening causes of chest pain and providing timely management.

• The patient's history should be obtained, including onset, quality, radiation, associated symptoms, and risk factors for cardiac disease.
• A physical examination focusing on cardiovascular and respiratory systems is essential.
• Cardiac biomarkers like troponin should be measured as soon as possible after presentation 1.
• Basic blood tests, including complete blood count, electrolytes, and renal function, should be obtained.
• A chest X-ray would help evaluate for pulmonary causes.
• If acute coronary syndrome is suspected, aspirin 325mg chewed should be administered, as it improves survival in patients with myocardial infarction 1.
• Consider nitroglycerin 0.4mg sublingually if systolic BP >90mmHg, and provide oxygen if saturation is low.
• Pain control with morphine 2-4mg IV may be appropriate.
• The patient should be placed on continuous cardiac monitoring while further evaluation proceeds.
• If the ECG shows ST-elevation MI, immediate cardiology consultation for possible percutaneous coronary intervention is needed. This systematic approach ensures rapid identification of life-threatening causes of chest pain while providing appropriate initial management.

From the FDA Drug Label

One tablet should be dissolved under the tongue or in the buccal pouch at the first sign of an acute anginal attack. The dose may be repeated approximately every 5 minutes until relief is obtained. If chest pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than is typically experienced, prompt medical attention is recommended Key Steps to Proceed:

• Give one nitroglycerin sublingual tablet at the first sign of chest pain
• The dose may be repeated approximately every 5 minutes, until the chest pain is relieved
• If the pain persists after a total of 3 tablets in a 15-minute period, or is different than typically experienced, seek emergency help 2
• Sit down when taking nitroglycerin sublingual tablets and use caution when standing up to avoid lightheadedness or dizziness 2

From the Research

Initial Assessment

When a patient presents with chest pain, the first priority is to establish whether the situation is life-threatening 3. The following steps can be taken:

• Assess the likelihood that signs and symptoms have a cardiac origin secondary to coronary artery disease 4
• Stratify the risk for ischemic complications using various scores derived from clinical trials 4
• Use critical pathways to improve guideline adherence 4

Diagnostic Work-up

The diagnostic work-up for chest pain should be based on conventional tools, such as:

• Clinical presentation 4, 5
• Physical examination 4
• Electrocardiogram (ECG) 4, 5
• Biochemical markers of myocardial damage, such as troponin 6, 5
• Provocative tests 7, 4

Risk Stratification

Risk stratification is crucial in managing patients with chest pain. The following strategies can be used:

• For patients with recurrent, low-risk chest pain, a single high-sensitivity troponin below a validated threshold can reasonably exclude acute coronary syndrome (ACS) within 30 days 6
• For patients with a normal stress test within the previous 12 months, repeat routine stress testing is not recommended as a means to decrease rates of major adverse cardiac events at 30 days 6
• For patients with non-obstructive coronary artery disease (CAD) on prior angiography within 5 years, referral for expedited outpatient testing is suggested rather than admission for inpatient evaluation 6

Clinical Gestalt

Clinical gestalt, or the physician's overall assessment of ACS likelihood, is an important tool in diagnosing chest pain patients. Studies have shown that:

• Clinical gestalt is better than its components at ruling in and ruling out ACS 5
• A positive troponin and an ischemic ECG are strong predictors of ACS 5
• Chest pain history typical of unstable angina is a moderate predictor of unstable angina, while pain history typical of acute myocardial infarction (AMI) is not a significant predictor of AMI in patients with a normal troponin and non-ischemic ECG 5