What is the diagnosis and treatment plan for inpatient admission for chest pain (Chest Pain)?

From the Guidelines

For an inpatient admission for chest pain, I recommend using a comprehensive evaluation and management plan that prioritizes the early identification or exclusion of life-threatening causes, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.

Key Components of the Evaluation Plan

• The plan should include a thorough history and physical examination, with attention to the quality, location, and radiation of the chest pain, as well as associated symptoms such as dyspnea, diaphoresis, and nausea.
• Initial workup should include an EKG, cardiac enzymes (with high-sensitivity troponins preferred), and chest imaging, as well as assessment of relevant risk factors such as hypertension, hyperlipidemia, diabetes, smoking, family history, and prior coronary artery disease.
• The differential diagnosis should consider acute coronary syndrome, pulmonary embolism, aortic dissection, GERD, musculoskeletal pain, and anxiety.

Treatment Plan

• The treatment plan should prioritize the immediate relief of ischemia and the prevention of myocardial infarction and death, with consideration of cardiac monitoring, serial troponins, stress testing, and medication management with aspirin, anticoagulation, and beta-blockers, as recommended in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 2.
• Consultation with cardiology and other relevant specialists should be considered as needed.
• The plan should also include monitoring for specific concerns, such as arrhythmias or signs of heart failure, and reassessment of the treatment plan based on diagnostic findings.

Risk Assessment and Stratification

• The evaluation plan should include a structured risk assessment, using tools such as the HEART score or the TIMI risk index, to stratify patients into low-, intermediate-, or high-risk categories.
• Low-risk patients may be considered for outpatient testing or observation, while high-risk patients should be admitted for inpatient management, as recommended in the 2011 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 3.

From the FDA Drug Label

The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were required to have either ECG changes compatible with new ischemia (without ST-elevation) or elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal.

The diagnosis for inpatient admission for chest pain is Acute Coronary Syndrome (ACS), which includes Unstable Angina (UA) or Non-ST-Elevation Myocardial Infarction (NSTEMI). The treatment plan includes:

• Clopidogrel (300 mg loading dose followed by 75 mg once daily)
• Aspirin (75 to 325 mg once daily)
• Other standard therapies such as heparin
• Possible use of GPIIb/IIIa inhibitors, lipid-lowering drugs, beta-blockers, and ACE inhibitors 4

From the Research

Diagnosis of Chest Pain

• The diagnosis of chest pain involves identifying low-risk patients and determining the likelihood of acute coronary syndrome (ACS) 5, 6, 7.
• Clinical decision aids such as the thrombolysis in myocardial infarction (TIMI) risk score, Global Registry of Acute Coronary Events (GRACE) scores, 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 can be used to risk-stratify patients 5.
• A cardiac workup is indicated in patients with suspected ACS, even if there are no ischemic changes on electrocardiography 7.

Treatment Plan for Inpatient Admission

• Patients with suspected myocardial ischemia are usually urgently referred for invasive coronary angiography and revascularization 7.
• In stable patients without evidence of ST elevation and ongoing myocardial ischemia, an initially conservative approach may be considered 7.
• Cardiac risk stratification is recommended before discharge, and imaging is necessary to exclude ischemia as an etiology 7.
• Noninvasive cardiac imaging modalities such as chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI can be used to evaluate patients with chest pain 7.
• An accelerated diagnostic protocol can be used to evaluate low-risk patients, with moderate-risk patients assessed over a 6-hour observation period with serial electrocardiograms and evaluation of cardiac-injury markers 8.

Evaluation of Chest Pain

• The evaluation of chest pain involves determining whether the pain is cardiac in origin or not, and if it is suspected to be cardiac, determining if it is secondary to an acute coronary syndrome 9.
• A systematic approach is used to determine the likelihood of significant coronary artery disease (CAD) based on the patient's history, risk factors, and electrocardiogram 9.
• Further invasive or non-invasive tests may be required to complete the patient's evaluation, depending on the assessed likelihood of CAD 9.