What is the management approach for acute chest pain?

Management of Acute Chest Pain

The management of acute chest pain requires immediate assessment, triage, and treatment within 5 minutes of presentation, with pain relief, hemodynamic stabilization, and specific interventions based on suspected etiology to reduce mortality and morbidity. 1

Initial Assessment and Triage

• Obtain a 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 2
• Draw blood samples for cardiac biomarkers (troponin T or I, CK-MB mass) on admission and at 10-12 hours after symptom onset 1
• Assess vital signs, level of consciousness, and signs of hemodynamic instability (heart rate <40 or >100/min, systolic BP <100 or >200 mmHg, cold extremities) 1
• Evaluate for high-risk features: ongoing pain, associated symptoms (sweating, nausea, vomiting), and ECG changes 1

Immediate Interventions

• Administer fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible for suspected ACS 1
• Provide pain relief with intravenous morphine titrated according to pain severity, even before ECG interpretation 1
• Administer sublingual or intravenous nitrates for suspected myocardial ischemia or to reduce cardiac filling pressures, unless contraindicated by hypotension or bradycardia 1
• Consider intravenous beta-blockers for tachycardia and hypertension in suspected myocardial ischemia 1
• Establish intravenous access and monitor cardiac rhythm continuously 1, 2

Management Based on ECG Findings

For ST-Segment Elevation:

• Initiate immediate reperfusion therapy (thrombolysis or primary PCI) within 30 minutes of diagnosis 1
• Transfer directly to cardiac catheterization laboratory if PCI facilities are available 1
• For patients with hemodynamic instability or shock, prioritize urgent revascularization 1

For ST-Depression or T-Wave Changes:

• Administer antithrombotic therapy (aspirin, low-molecular-weight heparin) 1, 3
• Consider adding clopidogrel, which has been shown to reduce incidence of death, stroke, and myocardial infarction 1
• Admit to coronary care unit or chest pain unit for monitoring 1

For Normal ECG but Ongoing Symptoms:

• Perform serial ECGs to detect evolving changes 2
• Measure troponin levels at presentation and 10-12 hours after symptom onset 1
• Consider supplemental diagnostic testing (echocardiography, chest X-ray) 1

Differential Diagnosis and Specific Management

• For suspected pulmonary embolism: Consider pulmonary scintigraphy or spiral CT examination 1
• For suspected aortic dissection: Perform transthoracic/transesophageal echocardiography, CT, or MR imaging 1, 3
• For suspected pneumothorax or pleuritis: Obtain chest X-ray 1, 4
• For suspected pericarditis: Evaluate ECG for diffuse ST elevations and PR depression 3

Chest Pain Unit Management

• Observe patients with low-to-moderate risk for 10-12 hours after symptom onset 1
• Equip unit with resuscitation capabilities, cardiac rhythm monitoring, and ST-segment monitoring 1
• Perform stress testing before discharge to identify severe myocardial ischemia at low workload 1
• Consider echocardiography and perfusion imaging for patients with non-diagnostic ECG 1

Common Pitfalls and Caveats

• Physical examination contributes minimally to diagnosing heart attack unless there is associated shock 2
• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia 2
• Women, elderly patients, and those with diabetes may present with atypical symptoms 2, 1
• The risk of inappropriate discharge without correctly diagnosing acute coronary syndrome is high without proper observation 1
• Only 10-15% of emergency department chest pain visits represent actual myocardial infarction, making differential diagnosis challenging 1, 5

Risk Stratification

• Assess for high-risk features: recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus 2
• Consider admission to coronary care unit for patients with ongoing pain, ischemic ECG changes, positive troponin, left ventricular failure, or hemodynamic abnormalities 1
• For patients without high-risk features, consider chest pain unit observation or outpatient follow-up 1