From the Guidelines
The patient with chest pain and numbness headaches, a normal electrocardiogram (EKG), no signs of stroke, and a pacemaker should be treated with a thorough cardiac evaluation, pain management, and consideration of their pacemaker function, prioritizing the administration of oxygen, nitrates, and beta-adrenergic blockers as indicated by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.
To address the patient's symptoms and potential cardiac issues, the following steps should be taken:
- Conduct a comprehensive cardiac workup, including blood tests (troponin, BNP), chest X-ray, echocardiogram, and stress test (if appropriate) to rule out acute coronary syndrome or other cardiac problems.
- Manage pain and symptoms with nitroglycerin 0.4 mg sublingual tablets for chest pain as needed, as recommended by the guideline 1, and consider acetaminophen 500-1000 mg every 6 hours for headaches.
- Evaluate pacemaker function by scheduling a pacemaker interrogation to ensure proper functioning, as the presence of a pacemaker may influence the choice of medications, such as the use of calcium channel blockers (CCBs) with caution due to potential interactions with the pacemaker.
- Monitor blood pressure and heart rate regularly, and consider the initiation of oral beta blockers within the first 24 hours in the absence of heart failure, low-output state, risk for cardiogenic shock, or other contraindications to beta blockade, as recommended by the guideline 1.
- Refer to a cardiologist for further evaluation and management, as they can provide specialized care and potential adjustments to treatment based on findings.
The administration of oxygen, nitrates, and beta-adrenergic blockers should be guided by the patient's clinical presentation and the recommendations outlined in the 2014 AHA/ACC guideline 1, with careful consideration of potential contraindications, such as the use of phosphodiesterase inhibitors, which are contraindicated with nitrates.
From the Research
Treatment Indications
The patient's symptoms of chest pain and numbness headaches, with a normal electrocardiogram (EKG) and no signs of stroke, and the presence of a pacemaker, suggest the need for careful consideration of treatment options.
- The use of aspirin is recommended for patients with acute myocardial ischemic syndromes unless contraindications are present 2.
- Early administration of aspirin (within two hours) following the onset of chest pain as part of first-aid management may be associated with increased survival compared to late administration 3.
- The optimal dose of aspirin for primary and secondary prevention of cardiovascular events is uncertain, but doses between 75-325 mg daily are commonly used 4.
Considerations for Patients with Pacemakers
There is limited information available on the specific treatment of patients with chest pain and numbness headaches who have a pacemaker.
- Metoprolol, a beta-blocker, has been shown to be effective in reducing mortality after myocardial infarction, and can be administered once daily or twice daily 5, 6.
- However, the use of beta-blockers in patients with pacemakers requires careful consideration, as they can affect heart rate and potentially interact with the pacemaker.
Treatment Options
Based on the available evidence, treatment options for the patient may include:
- Aspirin, in a dose of 75-325 mg daily, to reduce the risk of cardiovascular events 2, 4.
- Metoprolol, administered once daily or twice daily, to reduce mortality after myocardial infarction 5, 6.
- However, the specific treatment plan should be individualized and take into account the patient's medical history, the presence of the pacemaker, and other relevant factors.