From the Guidelines
If someone comes in with chest pain, immediately call emergency services (911 in the US) as this could indicate a heart attack or other life-threatening condition. While waiting for help, have the person sit down, rest, and try to stay calm. According to the most recent guidelines from the American Heart Association, as outlined in the 2024 American Heart Association and American Red Cross guidelines for first aid 1, if the person has been prescribed nitroglycerin for chest pain, they can take it as directed. Additionally, if aspirin is available and the person isn't allergic to it, they can chew a regular (325 mg) aspirin or take four low-dose (81 mg) aspirins, which helps prevent blood clotting, as supported by a 2020 systematic review 1.
Initial Evaluation
The initial evaluation of a patient with chest pain should include an ECG, which should be acquired and reviewed for ST-segment–elevation myocardial infarction (STEMI) within 10 minutes of arrival, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.
Risk Stratification
Risk stratification is crucial in managing patients with chest pain. The use of risk scores such as the HEART score can help identify patients at low, intermediate, and high risk for acute coronary syndrome (ACS), as discussed in the ACR Appropriateness Criteria for Chest Pain-Possible Acute Coronary Syndrome 1.
Management
The most important action for a person experiencing chest pain or other symptoms that might indicate a myocardial infarction is to activate EMS. While waiting for medical help to arrive, monitoring vital signs and being prepared to perform CPR if necessary is crucial. It is also important not to give the person any food or drink and to loosen tight clothing.
Noninvasive Imaging
Noninvasive imaging may be indicated for risk stratification and clinical management in both low-risk and intermediate-risk patients, as it can help identify patients with a significant ischemic burden who could benefit from coronary revascularization, as outlined in the ACR Appropriateness Criteria for Chest Pain-Possible Acute Coronary Syndrome 1.
Key Points
- Immediate medical attention is required for chest pain.
- Activation of EMS is the first step in management.
- Aspirin can be given if available and the person is not allergic.
- Nitroglycerin can be taken as directed if prescribed.
- Noninvasive imaging can aid in risk stratification and management.
- The HEART score and other risk stratification tools can help identify patients at risk for ACS.
From the FDA Drug Label
If the pain persists after a total of 3 tablets in a 15-minute, period, or is different than you typically experience, call your doctor or seek emergency help. Nitroglycerin may be used prophylactically 5 to 10 minutes prior to engaging in activities that might precipitate an acute attack. If chest pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than is typically experienced, prompt medical attention is recommended
The appropriate management for a patient presenting with chest pain is to:
- Take one nitroglycerin sublingual tablet at the first sign of chest pain
- Repeat the dose approximately every 5 minutes until relief is obtained
- Seek emergency help if the pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than typically experienced
- Consider prophylactic use of nitroglycerin 5 to 10 minutes prior to activities that might precipitate an acute attack 2 2
From the Research
Assessment of Chest Pain
The assessment of chest pain is a critical process that requires a structured approach to identify the underlying cause and provide timely management. According to 3, chest pain is a common reason for presentation in hospital emergency departments and general practice, and an acute coronary syndrome cannot be excluded on clinical grounds alone.
Initial Evaluation
The initial evaluation of chest pain involves determining whether the pain is cardiac in origin or not, as stated in 4. If the pain is suspected to be cardiac, the next step is to determine if it is secondary to an acute coronary syndrome that requires immediate referral to an emergency room.
Diagnostic Tests
Diagnostic tests such as a 12-lead electrocardiogram should be performed at the first available opportunity to exclude ST-segment-elevation myocardial infarction, as recommended in 3. Additionally, cardiac biomarkers and non-invasive tests for coronary disease can help clinicians minimize the risk of unexpected short-term adverse cardiac events.
Management
The management of chest pain may involve the administration of aspirin, which has been shown to improve survival in patients with non-traumatic chest pain, according to 5. Early administration of aspirin, within two hours of the onset of chest pain, may be associated with increased survival compared to late administration.
Key Considerations
Some key considerations in the management of chest pain include:
- Identifying the cause of chest pain in a safe, timely, and effective manner, as emphasized in 6
- Using a structured clinical assessment to evaluate chest pain, including patient history-taking, physical examination, and clinical investigations, as outlined in 6
- Adopting a strategic approach to deliver the best outcomes for patients with chest pain, as recommended in 3
- Being aware of the latest evidence-based guidelines and using them to inform clinical decision-making, as stated in 6