What is the treatment for chest pain?

Treatment of Chest Pain

Immediate treatment of chest pain requires rapid risk stratification and appropriate intervention based on suspected etiology, with high-risk features necessitating emergency medical services activation and hospital-based care. 1

Initial Assessment and Risk Stratification

High-Risk Features (Require Immediate Action)

• Severe, prolonged chest pain of acute onset
• Pain that interrupts normal activity
• Associated symptoms: cold sweat, nausea, vomiting, fainting, anxiety/fear
• New ischemic ECG changes
• Elevated cardiac troponins
• Hemodynamic instability
• New-onset left ventricular dysfunction (EF <40%)

Immediate Actions for Suspected Cardiac Chest Pain

1. Call emergency services (911/EMS) for immediate transport to hospital
2. Administer aspirin 325mg (chewable) if no contraindications 1, 2
3. Consider sublingual nitroglycerin if systolic BP >90 mmHg 1, 3
   • One tablet dissolved under tongue at first sign of chest pain
   • May repeat approximately every 5 minutes (up to 3 tablets in 15 minutes)
   • Caution: Do not use with erectile dysfunction medications
   • Common side effects: headache, dizziness, hypotension

Treatment Algorithm Based on Risk and Diagnosis

High-Risk Patients (Suspected ACS)

• Immediate hospital transfer 1
• 12-lead ECG within 10 minutes of presentation 2
• Serial cardiac troponin measurements 1, 2
• For STEMI: Immediate reperfusion therapy (PCI preferred if available within timeframe)
• For NSTEMI/Unstable Angina:
  • Antiplatelet therapy (aspirin + P2Y12 inhibitor)
  • Anticoagulation (heparin/LMWH)
  • Beta-blockers if no contraindications
  • Consider early invasive strategy based on risk assessment 1

Intermediate-Risk Patients

• Optimize guideline-directed medical therapy for those with known CAD 1
• Consider non-invasive testing (CCTA preferred for patients without known CAD) 1
• Consider stress testing for patients with known CAD and new/worsening symptoms 1

Special Populations

• Sickle Cell Disease patients: Emergency transfer to acute care setting and exclude acute chest syndrome 1
• Patients with non-cardiac chest pain: Consider psychological factors (anxiety, depression, panic disorder) and appropriate referral for cognitive-behavioral therapy 1, 4

Non-Cardiac Causes of Chest Pain

• Gastrointestinal: Most common non-cardiac cause (especially GERD) 4
  • Treatment: Proton pump inhibitors for suspected GERD
• Pulmonary: Consider pneumothorax, pulmonary embolism, pneumonia 5, 6
• Musculoskeletal: Pain typically reproducible with palpation or movement
• Psychiatric: May coexist with cardiac causes; requires appropriate mental health referral 1, 4

Common Pitfalls to Avoid

1. Dismissing atypical presentations: Women, elderly, and diabetic patients may present with atypical symptoms
2. Focusing only on cardiac causes: Remember the broad differential diagnosis 4, 6
3. Relying solely on ECG: Normal ECG does not exclude ACS
4. Premature reassurance: Single normal troponin does not exclude ACS; serial measurements are needed
5. Overlooking psychological factors: These can cause or worsen chest pain of any origin 4

Remember that chest pain requires urgent evaluation, as delays in diagnosis and treatment of life-threatening conditions like ACS, aortic dissection, or pulmonary embolism can significantly increase morbidity and mortality 5, 6.