What is the initial management for an inpatient presenting with chest pain?

Initial Management of Inpatient Chest Pain

For inpatients presenting with chest pain, the initial management should include a 12-lead ECG, cardiac biomarkers (preferably troponin), oxygen administration, aspirin, sublingual nitroglycerin, and adequate analgesia, followed by risk stratification to guide further management. 1

Immediate Assessment (First 10-20 Minutes)

1. Obtain 12-lead ECG immediately (within 10 minutes of presentation)

   • Look for ST-segment elevation, depression, T-wave changes, or new LBBB
   • Compare with previous ECG if available

2. Administer:

   • Oxygen via nasal cannula (especially if O₂ saturation <90%)
   • Aspirin 160-325 mg orally (unless contraindicated)
   • Sublingual nitroglycerin (unless systolic BP <90 mmHg or heart rate <50 or >100 bpm)
   • Adequate analgesia (morphine sulfate or meperidine) if pain persists

3. Draw blood for:

   • Cardiac troponin (preferably high-sensitivity troponin)
   • Complete blood count (to detect anemia)
   • Basic metabolic panel

Risk Stratification

Based on initial assessment, categorize patients into:

High-Risk Features (requiring urgent intervention):

• Persistent or recurrent chest pain
• Dynamic ST-segment changes (especially depression or transient elevation)
• Elevated troponin levels
• Hemodynamic instability
• Major arrhythmias (VT, VF)
• Early post-MI unstable angina
• Diabetes mellitus
• ECG pattern preventing ST-segment assessment

Management Based on ECG Findings:

If ST-segment elevation:

• Activate STEMI protocol
• Immediate reperfusion therapy (thrombolysis or primary PCI)
• Transfer to cardiac catheterization lab

If non-ST elevation or normal ECG:

• Continue medical therapy with:
  • Aspirin 75-150 mg daily
  • Consider P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel)
  • Anticoagulation (LMWH or unfractionated heparin)
  • Beta-blocker (unless contraindicated)
  • Nitrates for persistent pain

Ongoing Monitoring

• Continuous multi-lead ECG monitoring for arrhythmias and ischemic changes
• Repeat ECG if recurrent chest pain occurs
• Serial troponin measurements (at presentation and 6-12 hours later)
• Monitor for signs of hemodynamic instability (hypotension, pulmonary rales)

Additional Diagnostic Testing

• Echocardiography to assess left ventricular function and rule out other cardiovascular causes
• Consider coronary angiography for high-risk patients, especially those with:
  • Recurrent ischemia
  • Elevated troponin
  • Hemodynamic instability
  • Major arrhythmias

Important Considerations

• Rule out non-cardiac causes of chest pain (aortic dissection, pulmonary embolism, pneumothorax)
• For suspected aortic dissection: Withhold antithrombotic therapy and focus on pain relief and blood pressure control 1
• For suspected pulmonary embolism: Maintain continuous ECG and oxygen saturation monitoring 1

Common Pitfalls to Avoid

1. Delayed ECG acquisition - Should be obtained within 10 minutes of presentation
2. Failure to compare with previous ECGs - Essential for detecting new changes
3. Overlooking non-ST elevation ACS - These patients still require aggressive management
4. Administering nitroglycerin without IV access - Can cause profound hypotension
5. Assuming chest pain is non-cardiac in patients with risk factors - This is the most common reason for missed ACS 2

Remember that the timing of invasive management is determined by individual patient risk, with STEMI requiring intervention within 120 minutes of diagnosis, while other ACS presentations may allow for more deliberate evaluation and treatment.