Can a patient being worked up for chest pain continue taking Angiotensin-Converting Enzyme (ACE) inhibitors and beta blockers?

Continuing ACE Inhibitors and Beta Blockers During Chest Pain Workup

Yes, patients being worked up for chest pain can generally continue taking ACE inhibitors and beta blockers, as these medications are often beneficial in managing cardiovascular conditions that may be causing the chest pain. 1

Beta Blockers During Chest Pain Evaluation

• Beta blockers should be continued during chest pain workup as they are recommended within the first 24 hours for patients with suspected acute coronary syndrome who don't have contraindications such as heart failure, low cardiac output, or risk for cardiogenic shock 1
• For patients already on beta blockers for chronic conditions, it is reasonable to continue this therapy during chest pain evaluation 1
• Beta blockers help reduce myocardial oxygen demand by decreasing heart rate and blood pressure, which can alleviate ischemic symptoms 1
• Abrupt discontinuation of beta blockers in patients with coronary artery disease can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 2

Cautions with Beta Blockers

• Intravenous beta blockers should be avoided in patients with risk factors for cardiogenic shock 1
• Risk factors for shock include age >70 years, heart rate >110 beats per minute, systolic BP <120 mm Hg, and late presentation 1
• If signs of heart failure develop during chest pain workup, the beta blocker dose may need to be adjusted 2

ACE Inhibitors During Chest Pain Evaluation

• ACE inhibitors should be continued during chest pain workup, especially in patients with hypertension, diabetes, chronic kidney disease, or reduced left ventricular function 1
• For patients with normal left ventricular function, continuing ACE inhibitors is reasonable during evaluation for chest pain 1
• ACE inhibitors provide cardioprotection in patients with acute coronary syndromes and should not be discontinued during diagnostic evaluation 3
• ACE inhibitors may acutely improve endothelial function of coronary arteries, which could be beneficial during a chest pain episode 4

Combination Therapy Considerations

• The combination of beta blockers and ACE inhibitors has complementary effects on the sympathetic nervous system and renin-angiotensin-aldosterone system 3, 5
• This combination has been shown to reduce mortality in patients with cardiovascular disease 6, 3

Management Algorithm During Chest Pain Workup

1. Continue both medications unless specific contraindications develop:

   • For beta blockers: signs of heart failure, cardiogenic shock, severe bradycardia, or heart block 1, 2
   • For ACE inhibitors: hypotension (systolic BP <90 mmHg) or acute kidney injury 1

2. Monitor for potential side effects during the workup:

   • Beta blockers: bradycardia, hypotension, bronchospasm 2
   • ACE inhibitors: hypotension, worsening renal function 1

3. Consider temporary dose adjustment rather than discontinuation if mild side effects occur 1, 2

4. Reassess medication regimen after diagnosis is established based on findings 1

Common Pitfalls to Avoid

• Abruptly discontinuing beta blockers can worsen chest pain and precipitate cardiac events 2
• Stopping ACE inhibitors unnecessarily may remove cardioprotective benefits 1, 3
• Failing to monitor for hypotension when patients are receiving both medications 1, 3
• Not recognizing that these medications may be part of the treatment for the underlying cause of chest pain 1

In conclusion, while diagnostic evaluation for chest pain is ongoing, maintaining these medications is generally recommended unless specific contraindications develop or the clinical situation changes significantly 1.