What is the initial management approach for a patient presenting with severe chest pains?

Initial Management of Severe Chest Pain

The immediate management of a patient with severe chest pain should include obtaining a 12-lead ECG within 10 minutes of arrival, administering oxygen if saturation is <90%, providing aspirin 160-325mg, offering sublingual nitroglycerin (if no contraindications), and providing adequate analgesia with morphine if pain persists. 1, 2

Immediate Assessment (First 10-20 Minutes)

• Obtain a 12-lead ECG within 10 minutes of patient arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 2, 1
• Measure cardiac troponin as soon as possible after presentation 1
• Administer oxygen therapy only if oxygen saturation is <90% or if the patient has respiratory distress 2, 3
• Administer aspirin 160-325mg orally (chewable or water-soluble) immediately 2, 4
• Provide sublingual nitroglycerin unless systolic blood pressure is <90 mmHg or heart rate is <50 or >100 beats per minute 2, 5
• Administer morphine sulfate or alternative opiates for persistent severe chest pain 2
• Place patient on continuous cardiac monitoring with emergency resuscitation equipment nearby 1

Risk Stratification Based on ECG Findings

For Patients with ST-Segment Elevation or New LBBB:

• These patients are candidates for immediate reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention) 2
• The greatest benefit from thrombolysis occurs when initiated within 6 hours of symptom onset 2
• Symptoms consistent with acute MI and left bundle branch block should be managed like ST-segment elevation 2

For Patients without ST-Segment Elevation:

• Patients should not receive thrombolytic therapy 2
• Categorize as high-risk if they have: recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, or diabetes mellitus 2
• Consider early coronary angiography for high-risk patients 2

Additional Diagnostic Evaluation

• If initial ECG is nondiagnostic but clinical suspicion remains high, perform serial ECGs to detect potential ischemic changes 1
• Consider immediate echocardiography in patients with ongoing chest pain and inconclusive ECG to exclude alternative diagnoses (pulmonary embolism, pericarditis, aortic dissection) 2, 1
• Obtain blood work including troponin, serum creatinine, hemoglobin, hematocrit, platelet count, blood glucose, and INR (if on anticoagulants) 2
• Repeat troponin measurement at 1-3 hours if high-sensitivity assays are used 2

Differential Diagnosis Considerations

• Consider life-threatening non-cardiac causes of chest pain including:
  • Aortic dissection 1, 6
  • Pulmonary embolism 6, 7
  • Pneumothorax 6, 7
  • Pericarditis 1, 6
• Pleuritic chest pain (pain related to breathing) suggests pulmonary causes 7
• Constant pain unrelated to respiratory movements may indicate pulmonary hypertension, lung cancer, or mesothelioma 7

Common Pitfalls and Caveats

• Relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia 1
• Women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, vomiting, or lightheadedness 1
• Physical examination contributes minimally to diagnosing heart attack unless there is associated shock 1
• There is frequently a lack of correlation between intensity of symptoms and seriousness of disease 1
• Excessive use of nitroglycerin may lead to tolerance; use only the smallest dose required for effective relief 5
• Nitroglycerin may cause severe hypotension, particularly with upright posture 5

Disposition and Further Management

• Patients with STEMI or high-risk features should be treated according to ACS guidelines with consideration for immediate reperfusion therapy 1
• Patients with suspected NSTE-ACS should be observed in interdisciplinary emergency departments or chest pain units until the diagnosis is confirmed or ruled out 2
• In case of ongoing ischemia, defibrillator patches should be placed until urgent revascularization is performed 2
• If the diagnosis of NSTE-ACS is confirmed, assess the lipid profile in the early phase of admission 2