What is the most appropriate medication to relieve chest pain in a patient with ST segment elevation, tachycardia, and hypertension, who has been administered aspirin?

From the Guidelines

Nitroglycerin is the most appropriate medication to relieve this patient's chest pain, as it works by dilating coronary arteries, improving blood flow to the heart muscle, and reducing cardiac workload by decreasing preload and afterload. The patient is presenting with classic signs of an acute myocardial infarction (heart attack), including crushing central chest pain, diaphoresis, tachycardia, hypertension, and ST segment elevation on ECG. According to the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1, nitrates, such as nitroglycerin, should be administered sublingually every 5 minutes for up to three doses for continuing ischemic pain.

Some key points to consider when administering nitroglycerin include:

• It should be administered sublingually (0.4 mg) for rapid absorption and can be repeated every 5 minutes for up to three doses if pain persists and blood pressure remains adequate.
• Aspirin has already been appropriately administered to inhibit platelet aggregation.
• Morphine could be considered if nitroglycerin fails to relieve pain, but it's not the first-line agent, as stated in the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.
• Hydrocodone would be ineffective for acute cardiac chest pain.
• Lorazepam addresses anxiety but not the underlying cardiac ischemia.
• The patient's risk factors (hyperlipidemia, diabetes) further support the diagnosis of acute coronary syndrome, making nitroglycerin the optimal choice for immediate pain relief while definitive treatment is arranged.

It's also important to note that beta-adrenergic blockers, such as metoprolol, should be initiated orally 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 2014 AHA/ACC guideline 1. However, in this case, nitroglycerin is the most appropriate medication to relieve the patient's chest pain, and its administration should be prioritized.

From the FDA Drug Label

Morphine sulfate is an opioid agonist indicated for the management of pain not responsive to non-narcotic analgesics. The most appropriate medication to relieve chest pain in this patient is morphine, as it is indicated for the management of pain not responsive to non-narcotic analgesics, such as aspirin.

• The patient has been administered aspirin, which is a non-narcotic analgesic.
• Morphine can be used to manage pain that is not responsive to non-narcotic analgesics.
• However, it is crucial to exercise caution due to potential cardiovascular instability and hypotensive effect, especially in a patient with hypertension and tachycardia 2.

From the Research

Medication for Chest Pain Relief

The patient has already been administered aspirin, and the focus is on relieving chest pain in the context of ST segment elevation, tachycardia, and hypertension.

• Nitroglycerin is recommended to relieve chest pain and improve oxygen supply to the heart 3, 4, 5.
• Morphine can also be administered to relieve chest pain, especially if the patient does not respond to nitroglycerin or oxygen 3, 4, 5.
• Beta blockers may be used to lower blood pressure and reduce the heart's oxygen demand, but their use should be cautious in patients with tachycardia or hypotension 3, 6.

Additional Considerations

• The patient's condition, including ST segment elevation, suggests a potential myocardial infarction, and prompt medical attention, including possible percutaneous coronary intervention (PCI) or thrombolytic therapy, is crucial 3, 4.
• Anticoagulation therapy, such as unfractionated heparin or low-molecular-weight heparin, may be considered to prevent further clot formation 3, 6, 5.