What is the protocol for evaluating and managing acute chest pain (Angina Pectoris)?

From the Guidelines

The protocol for evaluating and managing acute chest pain (Angina Pectoris) involves immediate assessment and management, including obtaining vital signs, performing a focused history and physical examination, and ordering an electrocardiogram (ECG) within 10 minutes of arrival, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The initial evaluation should consider chest pain as a symptom that can manifest in various forms, including pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, which should all be considered anginal equivalents 1.

• High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury 1.
• Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1, and the evaluation should focus on the early identification or exclusion of life-threatening causes 1.
• Clinically stable patients presenting with chest pain should be included in decision-making, and information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion 1.
• Testing is not needed routinely for low-risk patients, and clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely 1. The use of structured risk assessment, such as the HEART score, can help identify patients who are at low, intermediate, or high risk for acute coronary syndrome (ACS) and guide further management 1.
• For patients with suspected ACS, administration of aspirin, supplemental oxygen, and antiplatelet therapy, as well as consideration of beta-blockers and nitroglycerin, can help reduce myocardial damage and improve survival 1.
• Noninvasive imaging modalities, such as rest or stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), echocardiography, or multidetector CT, can be used to evaluate patients with acute chest pain and help identify those with significant ischemic burden who may benefit from coronary revascularization 1. The goal of the protocol is to rapidly identify and treat life-threatening causes of chest pain, while also minimizing unnecessary testing and treatment in low-risk patients, and to improve patient outcomes and quality of life 1.

From the FDA Drug Label

In controlled clinical trials, metoprolol, administered orally two or four times daily, has been shown to be an effective antianginal agent, reducing the number of angina attacks and increasing exercise tolerance. A controlled, comparative, clinical trial showed that metoprolol was indistinguishable from propranolol in the treatment of angina pectoris. Nitroglycerin sublingual tablets are indicated for the acute relief of an attack or acute prophylaxis of angina pectoris due to coronary artery disease. Administer one tablet under the tongue or in the buccal pouch at the first sign of an acute anginal attack.

The protocol for evaluating and managing acute chest pain (Angina Pectoris) involves:

• Administering metoprolol orally two or four times daily to reduce the number of angina attacks and increase exercise tolerance 2
• Using nitroglycerin sublingual tablets for the acute relief of an attack or acute prophylaxis of angina pectoris due to coronary artery disease, by administering one tablet under the tongue or in the buccal pouch at the first sign of an acute anginal attack 3 Key considerations include:
• Monitoring for hypotension, particularly with upright posture, as severe hypotension may occur with small doses of nitroglycerin 3
• Avoiding concomitant use of nitroglycerin sublingual tablets with PDE-5 Inhibitors or sGC-Stimulators due to the risk of severe hypotension, syncope, or myocardial ischemia 3

From the Research

Evaluation Protocol

The protocol for evaluating and managing acute chest pain (Angina Pectoris) involves several steps:

• Initial evaluation based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS) 4
• Combination of age, sex, and type of chest pain to predict the likelihood of coronary artery disease as the cause of chest pain 4
• Use of decision aids such as the Marburg Heart Score and the INTERCHEST clinical decision rule to estimate ACS risk 4
• Twelve-lead electrocardiography to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions 4

Risk Stratification

Risk stratification is crucial in managing acute chest pain:

• Use of risk scores such as the TIMI risk score and Global Registry of Acute Coronary Events (GRACE) scores to predict the likelihood of ACS 5
• Asia-Pacific Evaluation of Chest Pain Trial (ASPECT), Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT), North American Chest Pain Rule (NACPR), and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population 5
• Computed Tomographic Angiography (CTA) for risk stratification in patients with acute chest pain, including the Triple Rule-out Concept in the Emergency Department 6

Diagnostic Testing

Diagnostic testing plays a crucial role in evaluating acute chest pain:

• Exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging for patients at low or intermediate risk of ACS 4
• Transthoracic echocardiography as the first-line imaging modality for evaluating patients with acute chest pain 7
• Computed tomography angiography may also be performed in selected cases 7

Management

Management of acute chest pain involves:

• Immediate transportation to the emergency department for patients with suspicion of ACS or changes on electrocardiography 4
• Early discharge for patients with low risk of ACS, using rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours 7
• Consideration of other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states for patients with low suspicion for ACS 4