What is the management approach for acute chest pain?

Management of Acute Chest Pain

The management of acute chest pain requires immediate assessment with a 12-lead ECG within 10 minutes of presentation, blood sampling for cardiac biomarkers, and risk stratification to determine appropriate treatment pathways based on the suspected diagnosis. 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 1
• 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
• Multi-lead ECG ischemia monitoring is recommended for continuous assessment 2

Immediate Interventions

• Administer fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible for suspected ACS 1, 2
• Provide pain relief with intravenous morphine titrated according to pain severity, but use caution due to potential interactions with oral antiplatelet therapy 2, 1
• Administer sublingual or intravenous nitrates for suspected myocardial ischemia or to reduce cardiac filling pressures, unless contraindicated by hypotension or bradycardia 1, 2
• Begin heparin therapy (preferably enoxaparin) in patients with suspected ACS 2

Management Based on ECG Findings

ST-Segment Elevation (STEMI)

• 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, 2
• If PCI is not available within 120 minutes, administer fibrinolytic therapy with weight-adjusted tenecteplase (half dose for patients >75 years old) 2
• Administer P2Y12 inhibitors: ticagrelor or prasugrel as first-line agents (if no contraindications), or clopidogrel if these are unavailable 2, 3

Non-ST Segment Elevation ACS (NSTEMI/UA)

• Administer aspirin, heparin, beta-blockers, and nitrates 2
• Consider early invasive strategy for high-risk patients (elevated troponin, hemodynamic instability, recurrent ischemia) 1, 2
• For patients receiving clopidogrel, a 300 mg loading dose followed by 75 mg daily maintenance dose is recommended 3
• Consider upstream GP2b3a inhibition for high-risk patients presenting early (<2h) after symptom onset 2

Risk Stratification and Disposition

• Assess for high-risk features: recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus 1, 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 low-to-moderate risk patients, observe for 10-12 hours after symptom onset in a chest pain unit with resuscitation capabilities and cardiac monitoring 1, 4
• Perform stress testing or other non-invasive testing for patients with normal initial evaluations but intermediate risk 2, 1

Differential Diagnosis and Specific Management

Aortic Dissection

• Use the ADD score in the pre-hospital setting to assess likelihood of aortic dissection 2
• Focus on pain relief and blood pressure control in suspected aortic dissection 2
• Target heart rate <60 beats/min and systolic blood pressure between 100-120 mmHg 2

Pulmonary Embolism

• Consider pulmonary scintigraphy or spiral CT examination for suspected pulmonary embolism 1, 5
• Assess for risk factors and characteristic symptoms (sudden onset, pleuritic pain, dyspnea) 5

Non-Cardiac Causes

• Consider musculoskeletal, gastrointestinal, or respiratory causes in patients with atypical chest pain and negative cardiac workup 6
• Recognize that even after thorough evaluation, a significant proportion of patients with chest pain may remain without a definitive diagnosis 6

Special Considerations

• For patients identified as CYP2C19 poor metabolizers, consider alternative P2Y12 inhibitors to clopidogrel due to diminished antiplatelet effect 3
• The CURE study demonstrated that clopidogrel plus aspirin reduced the risk of cardiovascular death, MI, or stroke by 20% compared to aspirin alone in patients with ACS 3
• The benefits of clopidogrel were independent of other cardiovascular therapies including heparin, GPIIb/IIIa inhibitors, beta-blockers, and ACE inhibitors 3