What is the initial assessment and treatment for a patient presenting with chest pain?

Initial Assessment and Treatment for Chest Pain

The initial assessment of a patient with chest pain should be completed within 10 minutes of arrival, with immediate administration of oxygen, sublingual nitroglycerin (unless systolic BP <90 mmHg or heart rate <50 or >100 bpm), adequate analgesia, and aspirin 160-325 mg orally. 1

Immediate Evaluation (First 10 Minutes)

• Obtain a 12-lead ECG immediately to determine if ST-segment elevation is present, which would indicate a potential STEMI requiring immediate reperfusion therapy 1
• Assess vital signs with particular attention to blood pressure, heart rate, respiratory rate, and oxygen saturation 1
• Perform focused physical examination looking for signs of valvular heart disease, hypertrophic cardiomyopathy, heart failure, and pulmonary disease 1
• Evaluate the quality of chest pain and symptom-oriented physical examination to help determine likelihood of coronary artery disease 1
• Draw blood for laboratory tests including cardiac troponins, CK-MB, hemoglobin, and basic chemistry panel 1

Initial Treatment

• Administer oxygen via nasal cannula 1
• Give sublingual nitroglycerin unless contraindicated (systolic BP <90 mmHg or heart rate <50 or >100 bpm) 1, 2
• Provide adequate analgesia with morphine sulfate or meperidine for persistent pain 1
• Administer aspirin 160-325 mg orally 1, 3
• Start continuous ECG monitoring for arrhythmias and ischemic changes 1
• Consider beta-blockers (such as metoprolol) for patients with tachycardia, hypertension, or ongoing ischemia without contraindications 1, 4

Treatment Based on ECG Findings

If ST-segment elevation or new LBBB:

• Immediate reperfusion therapy (thrombolysis or primary PCI) 1
• Continue aspirin, heparin, and other antiplatelet therapy as indicated 1

If no ST-segment elevation (ST depression, T-wave changes, or normal ECG):

• Administer aspirin 75-150 mg daily 1
• Consider clopidogrel (if not contraindicated) 1, 5
• Start LMWH or unfractionated heparin 1
• Continue beta-blockers and nitrates for persistent or recurrent chest pain 1
• Calcium antagonists may be used if beta-blockers are contraindicated 1

Observation Period (6-12 hours)

• Monitor for recurrence of chest pain with repeat ECG if symptoms return 1
• Obtain serial cardiac biomarkers (troponin) at 6-12 hours after initial presentation 1
• Watch for signs of hemodynamic instability (hypotension, pulmonary rales) 1
• Consider echocardiogram to assess left ventricular function and rule out other cardiovascular causes of chest pain 1

Risk Stratification

High-risk features requiring urgent intervention:

• Recurrent ischemia (chest pain or dynamic ECG changes) 1
• Elevated troponin levels 1
• Hemodynamic instability 1
• Major arrhythmias (ventricular tachycardia, ventricular fibrillation) 1
• Early post-infarction unstable angina 1
• Diabetes mellitus 1

Management based on risk:

• High-risk patients should undergo coronary angiography within 48 hours 1
• Low-risk patients may undergo non-invasive stress testing before discharge 1

Important Considerations

• Time is critical - every effort must be made to minimize delays in evaluation and treatment 1
• Prehospital administration of aspirin and nitroglycerin may improve outcomes in suspected ACS 6, 7
• Consider giving aspirin first, followed by nitroglycerin approximately 10 minutes later for potentially better pain control 7
• Continuous multi-lead ECG monitoring is recommended to detect dynamic changes 1
• For patients with undetermined diagnosis, a second troponin measurement after 6-12 hours is essential 1