What is the initial management for a patient presenting with chest pain suspected to be acute coronary syndrome?

From the Guidelines

The initial management for a patient presenting with chest pain suspected to be acute coronary syndrome (ACS) should focus on rapid assessment, stabilization, and treatment, with immediate administration of aspirin 325 mg chewed (or 162-325 mg orally) unless contraindicated due to allergy, as recommended by the most recent guidelines 1.

Key Initial Steps

• Provide supplemental oxygen if oxygen saturation is below 90% or the patient is in respiratory distress.
• Administer sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses if systolic blood pressure remains above 90 mmHg, which helps dilate coronary arteries and reduce cardiac workload, as suggested by previous guidelines 1.
• For pain relief, consider morphine sulfate 2-4 mg IV if pain persists despite nitroglycerin.
• Obtain a 12-lead ECG within 10 minutes of arrival and establish IV access for medication administration.
• Draw blood for cardiac biomarkers (troponin), complete blood count, basic metabolic panel, and coagulation studies.

Rationale

The approach to managing suspected ACS prioritizes reducing myocardial oxygen demand, improving coronary blood flow, and providing diagnostic information while preparing for definitive treatment, which may include anticoagulation therapy, antiplatelet agents, and potential coronary intervention depending on the specific type of ACS identified 1. The most recent guidelines emphasize the importance of rapid assessment and treatment, with a focus on evidence-based therapies like aspirin and P2Y12 inhibitors 1.

Considerations

• Patients with known CAD, including those with chronic stable angina, recent MI, or prior intervention, who contact a physician or other appropriate member of the health care team because of worsening or recurrent symptoms should be instructed to proceed rapidly to an ED, preferably one equipped to perform prompt reperfusion therapy 1.
• Every community should have a written protocol that guides EMS system personnel in determining where to take patients with suspected or confirmed ACS, with active involvement of local health care providers, particularly cardiologists and emergency physicians 1.

From the FDA Drug Label

One tablet should be dissolved under the tongue or in the oral cavity 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 you typically experience, call your doctor or seek emergency help.

The initial management for a patient presenting with chest pain suspected to be acute coronary syndrome using nitroglycerin sublingual tablets is to dissolve one tablet under the tongue or in the oral cavity at the first sign of chest pain, and the dose may be repeated approximately every 5 minutes until the chest pain is relieved 2.

• If the pain persists after a total of 3 tablets in a 15-minute period, or is different than typically experienced, the patient should call their doctor or seek emergency help.
• Key considerations for the use of nitroglycerin sublingual tablets include sitting down when taking the medication and using caution when standing up to avoid lightheadedness or dizziness.
• Patients should also be advised to avoid breastfeeding, consuming alcohol, and starting new prescription or non-prescription medicines or supplements without checking with their doctor first 2.

From the Research

Initial Management for Chest Pain Suspected to be Acute Coronary Syndrome

The initial management for a patient presenting with chest pain suspected to be acute coronary syndrome (ACS) involves several key steps:

• Aspirin is recommended for all patients with suspected ACS unless contraindicated 3
• Addition of a second antiplatelet (e.g., clopidogrel, ticagrelor, or prasugrel) is also recommended for most patients 3
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 3
• Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 3
• Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 3

Diagnostic Evaluation

• A 12-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions 4
• Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department 4
• Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging 4
• Consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states in patients with low suspicion for ACS 4

Pre-Hospital Management

• Pre-hospital practitioners should make individual treatment decisions based on the history and examination, the ECG findings, the facilities and diagnostic equipment available, and the transfer time to the nearest appropriate hospital 5
• Patients with acute ischemic chest pain should have oxygen, aspirin, nitrates, and opioid analgesia 5
• A 12-lead ECG should be performed within 5 minutes of initial assessment 5
• If the ECG reveals ST-segment elevation or presumed new LBBB, this signifies acute myocardial infarction and in most cases, immediate reperfusion therapy should be considered 5

Accelerated Diagnostic Protocol

• An accelerated diagnostic protocol can be used to evaluate patients with chest pain suggestive of acute coronary syndrome 6
• Low-risk patients can be identified by the clinical presentation and initial electrocardiogram, and can undergo immediate exercise treadmill testing 6
• Moderate-risk patients are assessed over a 6-hour observation period with serial electrocardiograms and evaluation of cardiac-injury markers 6