What is the guideline for managing chest pain and dyspnea?

Guidelines for Management of Chest Pain and Dyspnea of Cardiac Origin

The pre-hospital and initial management of chest pain and dyspnea requires a systematic approach based on rapid assessment, stabilization, and appropriate triage to facilities with adequate resources for definitive care. 1

Initial Assessment and Triage

• A 12-lead ECG should be obtained and reviewed within 10 minutes of patient presentation to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 2
• Cardiac troponin should be measured as soon as possible for patients with suspected acute coronary syndrome (ACS) 2
• ECG teletransmission by emergency medical services (EMS) teams is recommended for rapid diagnosis and treatment of arrhythmias 1
• Continuous ECG monitoring and venous access are mandatory in all patients with any type of cardiac arrhythmia 1

Management of Chest Pain

Suspected Acute Coronary Syndrome

• Administer fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible, and consider short-acting nitrates if there is no bradycardia or hypotension 2
• For STEMI patients, rapid transfer to centers with primary PCI capability is recommended 1
• High-risk features warranting immediate attention include recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus 2

Suspected Pericarditis

• Consider pericarditis in every patient in whom fibrinolysis is considered for presumed STEMI 1
• Stable uncomplicated pericarditis does not need specific management during pre-hospital transportation beyond pain relief 1
• Transfer patients to facilities where echocardiography and pericardiocentesis are available 1

Suspected Aortic Dissection

• Administer beta-blockers before other antihypertensive drugs 1
• Withhold antithrombotic therapy in suspected aortic dissection 1
• Transfer patients with high probability of aortic dissection to centers with 24/7 available aortic imaging and cardiac surgery 1

Management of Dyspnea

Suspected Acute Heart Failure

• In the absence of cardiogenic shock, provide: 1

  • Oxygen with a target saturation >94%
  • Sublingual/intravenous nitrates titrated according to blood pressure
  • Intravenous diuretics (furosemide)

• In cases of hemodynamic compromise and respiratory distress: 1

  • Initiate non-invasive ventilation promptly if respiratory distress is detected
  • Consider invasive ventilation if non-invasive ventilation is unsuccessful or contraindicated
  • Provide inotropic or vasopressor support as needed

Suspected Pulmonary Embolism

• Use clinical prediction scores to determine the likelihood of pulmonary embolism 1
• Maintain continuous ECG and blood oxygen saturation monitoring during transfer 1
• Consider point-of-care focused cardiac ultrasound (FoCUS) for evaluation of severity 1
• Transfer patients with severe symptoms or hemodynamic instability to intensive care units in centers equipped for thrombectomy 1

Suspected Cardiac Tamponade

• Perform pre-hospital risk assessment based on: 1

  • Presence of cardiogenic shock
  • Hemodynamic instability (heart rate >130 beats/min or <40, systolic blood pressure <90 mmHg)
  • Signs of increased systemic venous pressure (jugular vein distension)
  • Respiratory distress (respiration rate >25, blood oxygen saturation <90%)
  • Low voltage and/or electrical alternans on the ECG

• Consider ultrasound-guided pericardiocentesis in the pre-hospital setting if expertise and equipment are available 1

• Rapidly transfer patients with suspected tamponade to centers with capability for ultrasound-guided pericardiocentesis and/or cardiac surgery 1

Management of Arrhythmia-Related Chest Pain and Dyspnea

• Provide electrical cardioversion for supraventricular and ventricular arrhythmias associated with hemodynamic instability, loss of consciousness, or resistant angina pectoris 1
• Consider amiodarone for prevention of recurrent life-threatening arrhythmia in patients with resuscitated cardiac arrest 1
• Consider adenosine (6-12 mg IV bolus) in selected cases of re-entrant supraventricular tachycardia 1
• Transfer all patients with symptomatic cardiac arrhythmia to facilities with continuous ECG monitoring capability 1

Common Pitfalls and Special Considerations

• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia, as other conditions may show comparable response 2
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, or vague abdominal symptoms 2
• Physical examination contributes minimally to diagnosing heart attack unless there is associated shock 2
• Patients often delay seeking medical attention for chest pain, with longer delays in older patients and those in rural areas 2

Organizational Considerations

• Well-defined hub and spoke networks are needed for all cardiovascular emergencies, similar to those existing for STEMI 1
• The presence of emergency physicians on-scene is recommended for chest pain or acute dyspnea of suspected cardiac origin 1
• Regional networks and coordination between pre-hospital services and hospital departments are essential for providing continuous and consistent care 1