What is the management of chest pain?

Management of Chest Pain

Patients with chest pain exhibiting red flags require immediate hospital care regardless of the cause, as these symptoms may indicate potentially life-threatening conditions including myocardial infarction, unstable angina, aortic dissection, pulmonary embolism, or pneumothorax. 1

Immediate Assessment and Triage

• Severe, prolonged chest pain of acute onset requires immediate action regardless of cause, with differential diagnosis including heart attack, unstable angina, aortic dissection, pulmonary embolism, and pneumothorax 2
• Obtain and review a 12-lead ECG within 10 minutes of patient presentation to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 3
• Measure cardiac troponin as soon as possible for patients with suspected acute coronary syndrome 3
• Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby 1, 3

Red Flags Requiring Immediate Action

• Pain that interrupts normal activity 2
• Presence of accompanying symptoms such as cold sweat, nausea, vomiting, fainting, or anxiety/fear 2
• Severe, prolonged chest pain of acute onset 2
• Associated autonomic nervous system stimulation (patient appears pale, diaphoretic, cool to touch) 2
• ST-segment elevation or depression on ECG 2

Initial Management Algorithm

1. For all patients with chest pain:

   • Administer fast-acting aspirin (250-500mg) if not contraindicated 2, 3
   • Monitor vital signs and cardiac rhythm continuously 3
   • Obtain focused history including characteristics and duration of symptoms 3

2. For suspected myocardial infarction:

   • Consider short-acting nitrate if no bradycardia or hypotension 2
   • Consider opiates for pain and anxiety relief 2
   • If ST-segment elevation indicates evolving Q-wave infarction, start thrombolytic treatment within 30 minutes 2

3. For suspected acute coronary syndrome:

   • Start low-molecular-weight heparin in the emergency department 2
   • If troponin T is elevated (>0.1 g/L), heparin improves prognosis 2

4. Transport decision:

   • Call for ambulance transport to hospital for all patients with red flags 1
   • Patients with STEMI or cardiogenic shock should be sent directly to hospitals with interventional capability 1
   • Healthcare provider should remain with patient until ambulance arrives 2

Diagnostic Approach

• Obtain ECG to identify myocardial ischemia, arrhythmias, or other cardiac abnormalities 2
• Draw blood samples for CK-MB mass and troponin T or I on admission and at 10-12 hours after symptom onset 2
• Perform chest X-ray to evaluate for other potential cardiac, pulmonary, or thoracic causes of chest pain 3
• Consider supplemental ECG leads V7-V9 to rule out posterior myocardial infarction when initial ECG is nondiagnostic 3

Management Based on Risk Stratification

High-Risk Patients (Suspected ACS or Life-Threatening Condition)

• Admit to specialized coronary care or intensive care unit without delay 2
• Prioritize patients with severe continuing pain, ischemic ECG changes, positive troponin test, left ventricular failure, or other hemodynamic abnormalities 2
• For STEMI patients, door-to-needle time should be under 30 minutes 2
• Consider immediate coronary angiography for primary percutaneous coronary intervention if facilities are available 2

Patients Without Overt Signs of ACS

• Perform comprehensive diagnostic workup including physical examination, chest X-ray, arterial blood gas determination, clinical chemistry, and echocardiography if hemodynamic disturbances are present 2
• Consider CT or MR scan if aortic dissection is suspected 2
• Consider pulmonary scintigraphy or spiral CT when pulmonary embolism is suspected 2
• Perform exercise test before discharge to reveal possible severe myocardial ischemia 2

Important Pitfalls to Avoid

• Do not rely solely on pain severity to determine urgency, as severity is a poor predictor of imminent complications 1
• Do not delay treatment while waiting for definitive diagnosis in patients with red flags 1
• Physical examination contributes minimally to diagnosing myocardial infarction unless shock is present 2, 1
• Do not use relief with nitroglycerin as a diagnostic criterion for myocardial ischemia 3
• Do not abruptly discontinue beta-blockers in patients with coronary artery disease, as this can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 4

Special Considerations

• Women may differ from men in symptom presentation, using words like 'tearing,' 'terrifying,' 'tiring,' and 'intolerable' more frequently, and may have pain more often in the back, neck, and jaw 2
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, or lightheadedness 3
• In patients with bronchospastic disease who require beta-blockers, use the lowest possible dose of a beta-1 selective agent like metoprolol 4