What are specific return precautions for concerning symptoms such as chest pain or shortness of breath?

Return Precautions for Concerning Symptoms: Chest Pain and Shortness of Breath

Patients experiencing chest pain or shortness of breath should be instructed to call 9-1-1 immediately if symptoms are unimproved or worsening 5 minutes after onset, as these may indicate life-threatening conditions requiring urgent medical attention. 1

Chest Pain Return Precautions

When to Call 9-1-1 Immediately

• Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw that is:
  • Unrelieved or worsening after 5 minutes 1
  • Accompanied by shortness of breath, nausea, sweating, or lightheadedness 1
  • Associated with syncope or presyncope 1
  • Lasting more than 20 minutes at rest 1
  • Accompanied by hemodynamic instability 1

For Patients Previously Prescribed Nitroglycerin

• If chest pain occurs, take one dose of nitroglycerin immediately
• If symptoms are not significantly improved after 5 minutes, call 9-1-1 immediately
• For patients with chronic stable angina whose symptoms significantly improve after one nitroglycerin, they may:
  • Repeat nitroglycerin every 5 minutes for a maximum of 3 doses
  • Call 9-1-1 if symptoms have not completely resolved after 3 doses 1

Additional Warning Signs

• Chest pain occurring with less exertion than usual
• Chest pain that awakens the patient from sleep
• New onset of chest pain in patients ≥75 years, especially when accompanied by shortness of breath, syncope, acute delirium, or unexplained fall 1
• Chest pain that radiates to the arms, jaw, or back 1, 2
• Chest pain accompanied by diaphoresis (cold sweat) 1

Shortness of Breath Return Precautions

When to Call 9-1-1 Immediately

• Sudden onset of severe shortness of breath
• Shortness of breath accompanied by chest pain 1
• Shortness of breath with dizziness, fainting, or confusion 2
• Shortness of breath with bluish discoloration of lips or face
• Shortness of breath that prevents speaking in complete sentences
• Shortness of breath that worsens when lying flat
• Shortness of breath accompanied by swelling in the feet/ankles 1

Special Considerations

For Patients with Known Cardiovascular Disease

• Report any symptoms that occur during sexual activity:
  • Chest pain
  • Shortness of breath
  • Rapid or irregular heart rate
  • Dizziness
  • Insomnia after sexual activity
  • Fatigue the day after sexual activity 1

For Patients with Sickle Cell Disease

• Any acute chest pain requires emergency transfer by EMS to an acute care setting 1

Instructions for Patients

1. For chest pain or shortness of breath that is severe, worsening, or concerning:

   • Call 9-1-1 immediately
   • Do not drive yourself to the hospital
   • Take aspirin (162-325mg) if instructed by emergency dispatcher and not contraindicated 1

2. While waiting for emergency services:

   • Rest in a position that makes breathing easier
   • Loosen tight clothing
   • Use prescribed medications as directed (e.g., nitroglycerin for cardiac chest pain) 1

3. For patients with less severe symptoms that resolve quickly:

   • Contact your healthcare provider within 24 hours to discuss the episode
   • Do not ignore even mild symptoms, especially if they are recurrent 1

Common Pitfalls to Avoid

• Delay in seeking care: Many patients delay calling for help due to denial or hoping symptoms will resolve. This can lead to worse outcomes, especially in cardiac conditions where "time is muscle." 1

• Misattribution of symptoms: Chest pain or shortness of breath may be incorrectly attributed to indigestion, muscle strain, or anxiety. Even if these are possible causes, life-threatening conditions should be ruled out first. 3, 4

• Using someone else's medication: Patients without prescribed nitroglycerin should not borrow medication from others. 1

• Ignoring atypical presentations: Women, elderly patients, and those with diabetes may present with less typical symptoms. Fatigue, shortness of breath, or nausea without chest pain may be the only symptoms in these populations. 1

By following these return precautions and seeking prompt medical attention when concerning symptoms occur, patients can significantly improve their outcomes in potentially life-threatening conditions.