What is the initial management of acute chest pain?

From the Guidelines

The initial management of acute chest pain should prioritize rapid assessment and stabilization, with a focus on identifying life-threatening causes and determining clinical stability, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The first step involves ensuring the patient is placed on continuous cardiac monitoring, establishing IV access, administering supplemental oxygen if oxygen saturation is below 94%, and obtaining a 12-lead ECG within 10 minutes of arrival.

• Administer aspirin 325mg chewed immediately unless contraindicated, as recommended by the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.
• For suspected acute coronary syndrome, give nitroglycerin 0.4mg sublingually every 5 minutes for up to 3 doses if systolic blood pressure remains above 90mmHg.
• Pain control with morphine 2-4mg IV may be necessary if chest pain persists.
• Draw cardiac biomarkers (troponin), complete blood count, basic metabolic panel, and coagulation studies.
• Consider additional medications based on ECG findings: for ST-elevation myocardial infarction, add P2Y12 inhibitors like clopidogrel 600mg loading dose. These interventions are critical as the first hour of chest pain management significantly impacts outcomes by potentially limiting myocardial damage, as emphasized in the 2021 guideline 1. The dual goals are to relieve symptoms while simultaneously determining the underlying cause, which could range from cardiac ischemia to pulmonary embolism, aortic dissection, or non-cardiovascular conditions.
• Patients with stable angina or noncardiac chest pain that is not life-threatening should be managed as outpatients, whereas those with suspected acute coronary syndrome or other life-threatening conditions require prompt hospital evaluation and management 1.
• The use of a 12-lead ECG is pivotal in the evaluation of chest pain, as it can identify and triage patients with STEMI to urgent coronary reperfusion, and other ST-T abnormalities consistent with possible ischemia also mandate prompt evaluation in a hospital setting 1.

From the FDA Drug Label

If possible, patients should sit down when taking nitroglycerin sublingual tablets and should use caution when returning to a standing position. 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

The initial management of acute chest pain includes administering nitroglycerin sublingually at the first sign of an acute anginal attack. The patient should sit down and dissolve one tablet under the tongue or in the buccal pouch. The dose may be repeated every 5 minutes until relief is obtained, up to a maximum of 3 tablets in a 15-minute period. If chest pain persists, prompt medical attention is recommended 2.

Key points:

• Administer nitroglycerin sublingually at the first sign of an acute anginal attack
• Sit down when taking nitroglycerin
• Dissolve one tablet under the tongue or in the buccal pouch
• Repeat dose every 5 minutes as needed, up to 3 tablets in 15 minutes
• Seek prompt medical attention if chest pain persists 2

From the Research

Initial Management of Acute Chest Pain

The initial management of acute chest pain involves several key steps, including:

• Administering aspirin to all patients with suspected acute coronary syndrome (ACS) unless contraindicated 3
• Adding a second antiplatelet agent, such as clopidogrel, ticagrelor, or prasugrel, for most patients 3
• Providing parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 3
• Using proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher risk of gastrointestinal bleeding 3
• Administering statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine to relieve chest pain, and oxygen as needed 3

Timing of Aspirin Administration

The timing of aspirin administration is crucial, with early administration (within 2 hours of chest pain onset) associated with increased survival compared to late administration (median 3.5 hours or in-hospital) 4

• A systematic review found that early administration of aspirin improved survival at 7 days, 30 days, and 1 year, although the evidence was of very low certainty due to limitations in study design and imprecision of the evidence 4
• A population-based analysis estimated that self-administering aspirin within 4 hours of severe chest pain onset could delay 13,016 deaths annually in the US population, with a cost-effectiveness ratio of $3.70 per year of life saved 5

Use of Nitroglycerin

Nitroglycerin is also an important medication in the management of acute chest pain, particularly in patients with ST-segment elevation myocardial infarction (STEMI)

• A retrospective study found that giving nitroglycerin 10 minutes after aspirin dosing (compared to giving them simultaneously) led to a greater than 20% reduction in need for additional nitroglycerin, a greater than 7% decrease in subjective pain experienced by the patient, and reduced need for additional opioids in patients with STEMI ischemia 6
• The study suggested that the timing of aspirin and nitroglycerin administration may impact patient outcomes, with further prospective trials needed to confirm these findings 6

Prehospital Aspirin Administration

Prehospital aspirin administration is an important aspect of acute chest pain management, with national practice guidelines recommending early aspirin administration to reduce mortality in ACS

• An analysis of the 2011 National EMS Information System (NEMSIS) database found that only 45.4% of patients with suspected cardiac ischemia received aspirin from EMS providers, with disparities in administration among different patient groups 7
• The study highlighted the need for improved prehospital aspirin administration for patients with suspected cardiac ischemia, with further research needed to explore reasons for disparities in administration 7