Management of Chest Pain
The management of chest pain requires immediate assessment to identify life-threatening conditions, with initial interventions including ECG, aspirin administration, and appropriate triage based on risk stratification. 1, 2
Initial Assessment and Triage
- Obtain a focused history including characteristics and duration of symptoms, associated features, and cardiovascular risk factors 1
- Perform a 12-lead ECG within 10 minutes of presentation to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 2
- Measure cardiac troponin as soon as possible in patients with suspected acute coronary syndrome (ACS) 2
- Initiate continuous cardiac monitoring for patients with suspected ACS 2
- Severe prolonged chest pain of acute onset requires immediate hospital care regardless of cause 1
Key History Elements to Assess
- Nature of pain: Anginal symptoms typically present as retrosternal discomfort (pressure, heaviness, tightness) 1
- Onset and duration: Anginal symptoms gradually build over minutes; sudden onset of ripping pain suggests aortic syndrome 1
- Location and radiation: Pain localized to a very limited area or radiating below the umbilicus is unlikely to be cardiac 1
- Precipitating and relieving factors: Exertion-induced pain relieved by rest suggests angina 1
- Associated symptoms: Cold sweat, nausea, vomiting, fainting, or anxiety/fear suggest serious conditions 1
Risk Stratification
High-Risk Features (Requiring Immediate Attention)
- Recurrent ischemia (chest pain or dynamic ST segment changes) 1
- Elevated troponin levels 1
- Hemodynamic instability (hypotension, pulmonary rales) 1
- Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
- Early post-infarction unstable angina 1
Low-Risk Features
- Pain that varies with respiration, body position, or food intake 1
- Well-localized chest wall pain with local tenderness 1
- Normal ECG and troponin levels without recurrent symptoms 3
Initial Management
For Suspected ACS
- Administer aspirin 250-500 mg (chewable or water-soluble) immediately 1
- Provide sublingual or intravenous nitrates for persistent or recurrent symptoms if no bradycardia or hypotension 1
- Initiate beta-blocker therapy (or calcium channel blockers if beta-blockers are contraindicated) 1
- Start heparin therapy 1
- Consider opiates for pain relief and anxiety 1
For High-Risk Patients
- Administer GP IIb/IIIa receptor blocker while preparing for angiography 1
- Arrange urgent coronary angiography 1
- Consider revascularization (PCI or CABG) based on coronary anatomy 1
For Intermediate-Risk Patients
- Continue medical therapy with aspirin, heparin, beta-blockers, and nitrates 1
- Perform serial ECGs and troponin measurements 1
- Consider stress testing or other non-invasive imaging if initial tests are negative 1, 2
For Low-Risk Patients
- After ruling out MI and high-risk ACS, patients may be safely discharged with appropriate follow-up 3
- Arrange further testing as needed (e.g., exercise stress testing, coronary CT angiography) 2, 4
Common Pitfalls and Caveats
- Physical examination contributes minimally to diagnosing heart attack unless there is associated shock 1
- Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia 2
- There is frequently a lack of correlation between symptom intensity and disease severity 1
- Women, elderly patients, and those with diabetes may present with atypical symptoms 2, 5
- 2-4% of patients with evolving myocardial infarction are inappropriately discharged due to normal ECG findings 1
- Only 30-40% of patients who develop acute myocardial infarction initially have ST-elevations on admission ECG 1