What are the guidelines for managing chest pain suspected to be of cardiac origin?

From the Guidelines

Management of suspected cardiac chest pain requires immediate evaluation and intervention, with the most recent guidelines from 2024 emphasizing the importance of rapid assessment and treatment 1. Patients should be rapidly assessed with a 12-lead ECG within 10 minutes of presentation, vital signs monitoring, and blood tests including cardiac troponins.

Initial Assessment and Treatment

• Initial treatment typically includes aspirin (162-324mg chewed immediately) as it improves survival in patients with myocardial infarction, with a low rate of major complications associated with its administration 1.
• Nitroglycerin (0.4mg sublingual every 5 minutes for up to 3 doses if systolic BP remains >90mmHg) and oxygen if saturation is below 94% should also be considered.
• Additional medications often include morphine (2-4mg IV) for pain relief, beta-blockers such as metoprolol, and anticoagulation with heparin or low molecular weight heparin.

Risk Stratification and Further Management

• Clinical risk assessment is used to determine the pretest probability of coronary artery disease (CAD), with methods including the Diamond and Forrester method, Framingham risk score, coronary calcium score, and Duke Clinical Score 1.
• In patients with a high clinical probability of CAD, imaging is used to characterize known and unknown ischemic heart disease, and to determine the presence, extent, and severity of obstructive coronary narrowing.
• If an acute coronary syndrome is confirmed, dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor should be initiated, along with high-intensity statins.
• Patients with ST-elevation myocardial infarction require immediate reperfusion therapy, ideally primary percutaneous coronary intervention within 90 minutes of first medical contact, or fibrinolytic therapy if PCI is not available within 120 minutes 1.

Key Considerations

• The American Heart Association does not recommend administration of oxygen in healthcare settings for people with acute coronary syndromes who are not hypoxic 1.
• Emphasis should be placed on specific aspects of symptoms that suggest their origin in terms of probable ischemia, rather than using the term "atypical chest pain" 1.

From the Research

Guidelines for Managing Chest Pain Suspected to be of Cardiac Origin

The management of chest pain suspected to be of cardiac origin involves several key steps and therapies.

• Initial assessment and diagnosis are critical, with an electrocardiogram (ECG) being a fundamental tool in the primary care setting 2.
• For patients with suspected acute coronary syndrome (ACS), aspirin is recommended unless contraindicated, along with a second antiplatelet agent (such as clopidogrel, ticagrelor, or prasugrel) for most patients 3.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is also recommended 3.
• Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 3.

Specific Recommendations for ST-Segment Elevation Myocardial Infarction and Non-ST-Segment Elevation ACS

• For patients with an ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible. If PCI will be delayed for more than 120 minutes, fibrinolytic therapy should be used first 3.
• For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is typically not recommended 3.
• The use of low-molecular-weight heparins and glycoprotein IIb/IIIa antagonists in acute coronary syndromes has been found to be safe and effective, offering enhanced clinical benefits when combined 4.

Importance of Antiplatelet Intervention and Risk Stratification

• Antiplatelet agents, including aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitors, play a crucial role in the management of ACS, with the choice of agent depending on the patient's risk stratification 5.
• The TIMI risk score for patients with unstable angina/non-ST-elevation myocardial infarction provides a useful tool for therapeutic decision-making, and simultaneous assessment of troponin, C-reactive protein, and brain natriuretic peptide at presentation offers incremental prognostic information 5.
• An early invasive strategy, including catheterization and revascularization within 48 hours, is recommended for high-risk patients, coupled with medical therapy that includes aspirin, beta-blockers, unfractionated heparin or low-molecular-weight heparin, and clopidogrel for those undergoing PCI 5.