What is the management for severe sudden onset chest pain?

Management of Severe Sudden Onset Chest Pain

Patients with severe sudden onset chest pain should be immediately transported to the nearest emergency department, preferably by emergency medical services (EMS), as this is a potential life-threatening condition requiring prompt evaluation and treatment. 1

Initial Assessment and Actions

• Patients experiencing severe sudden onset chest pain should be instructed to call emergency services (9-1-1) immediately, especially when the discomfort is moderate to severe or sustained 2
• Healthcare providers receiving calls about chest pain should advise patients that evaluation cannot be performed via telephone and should direct them to seek immediate medical attention 2
• Patients with known coronary artery disease (CAD) who experience worsening or recurrent symptoms should proceed rapidly to an emergency department equipped to perform prompt reperfusion therapy 2
• Upon arrival at a healthcare facility, the patient should be placed on cardiac monitor immediately with emergency resuscitation equipment nearby 1

Immediate Management Protocol

• Perform and evaluate ECG within 10 minutes of arrival to identify potential ST-elevation myocardial infarction (STEMI) or other acute cardiac conditions 1
• Obtain vital signs and a focused history to identify potential causes of chest pain 1
• Administer fast-acting aspirin (250-500mg) if not contraindicated 1
• For suspected myocardial infarction, administer short-acting nitrate if no bradycardia or hypotension is present 1, 3
• Consider opiates for pain and anxiety relief in appropriate cases 1

Transport Decisions

• Every community should have a written protocol guiding EMS personnel in determining where to take patients with suspected or confirmed acute coronary syndrome (ACS) 2
• Patients with suspected ACS should generally be taken to the nearest appropriate hospital 2
• Patients with known STEMI and/or cardiogenic shock should be sent directly to hospitals with interventional and surgical capability 2
• Private vehicle transport should be avoided, as approximately 1 in 300 chest pain patients transported by private vehicle goes into cardiac arrest en route 1

Differential Diagnosis Considerations

• Chest pain may indicate various life-threatening conditions including myocardial infarction, unstable angina, aortic dissection, pulmonary embolism, or pneumothorax 1, 4
• Sudden onset of ripping chest pain with radiation to the back is highly suspicious for acute aortic syndrome 5
• Chest pain described as "worst chest pain of my life," especially in patients with hypertension or known aortic valve disease, significantly increases the likelihood of aortic dissection 5
• Coronary artery vasospasm should be considered among the differentials in patients presenting with chest pain and ST-segment elevations that resolve with nitroglycerin 3

Special Considerations

• Elderly patients or those with diabetes may present with atypical symptoms and require heightened vigilance 1, 5
• In a large study of consecutive patients with chest pain suspected to be of cardiac origin who were transported to the ED via ambulance, one-third had a final diagnosis of myocardial infarction, one-third had unstable angina, and one-third had a noncardiac cause 2
• Only 1.5% of patients developed cardiopulmonary arrest before arrival at the hospital or in the ED, indicating that there is usually adequate time for transport to an appropriate facility 2

Important Pitfalls to Avoid

• Do not rely solely on pain severity to determine urgency, as severity is a poor predictor of imminent complications such as cardiac arrest 1
• Avoid delaying treatment while waiting for definitive diagnosis in patients with red flags 1
• Do not dismiss symptoms over the telephone, as proper evaluation requires physical examination, ECG, and appropriate blood tests 2
• Remember that physical examination contributes minimally to diagnosing myocardial infarction unless shock is present 1