What is the management for sudden severe chest pains?

Management of Sudden Severe Chest Pain

For patients experiencing sudden severe chest pain, immediate medical attention should be sought as this may indicate potentially life-threatening conditions including myocardial infarction, unstable angina, aortic dissection, pulmonary embolism, or pneumothorax. 1

Initial Assessment and Actions

• Call emergency services immediately for moderate to severe or sustained chest pain, as telephone evaluation is inadequate for proper assessment 1
• Upon arrival at a healthcare facility, patients should be placed on cardiac monitor with emergency resuscitation equipment nearby 1
• An ECG should be performed and reviewed within 10 minutes of arrival to identify potential ST-elevation myocardial infarction or other acute cardiac conditions 2, 1
• Vital signs and a focused cardiovascular examination should be performed to aid in diagnosis and identify complications 2
• Blood samples should be drawn for cardiac biomarkers (troponin) as soon as possible after presentation to the emergency department 2, 3

Immediate Interventions

• Administer fast-acting aspirin (250-500mg, chewable or water-soluble) if not contraindicated 1, 3
• Provide pain relief with sublingual or intravenous nitrates for suspected myocardial ischemia, unless contraindicated by hypotension or bradycardia 3
• Consider opiates (e.g., morphine) for severe pain and anxiety relief, titrated according to pain severity 3
• Ensure adequate hydration, especially in patients with chronic kidney disease who may require coronary angiography 2

Management Based on ECG Findings

• For ST-segment elevation myocardial infarction (STEMI), initiate immediate reperfusion therapy (thrombolysis or primary PCI) within 30 minutes of diagnosis 3
• For non-ST-segment elevation acute coronary syndrome (NSTE-ACS), implement an early invasive strategy for high-risk patients (troponin positive) 2
• For suspected coronary vasospasm with transient ST-elevation, calcium channel blockers alone or in combination with nitrates are recommended 2, 4

Differential Diagnosis Considerations

• Assess for specific chest pain characteristics to help determine the cause:
  • Anginal symptoms typically present as retrosternal discomfort (pressure, heaviness, tightness) that gradually builds in intensity 2
  • Sudden onset of ripping chest pain, especially with radiation to the back, is highly suspicious for acute aortic syndrome 2, 1
  • Sharp chest pain that increases with inspiration and lying supine suggests acute pericarditis 2
  • Pain localized to a very limited area or radiating below the umbilicus is unlikely related to myocardial ischemia 2

Special Considerations

• Women should receive the same pharmacological therapy as men for acute care and secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding risk 2
• Elderly patients or those with diabetes may present with atypical symptoms (throat pain, upper abdominal pain, or heartburn) and require heightened vigilance 1, 5
• For patients with recent cocaine or methamphetamine use, manage similarly to those without substance-related ACS, except in cases of acute intoxication where benzodiazepines may be used 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, 6
• Avoid delaying treatment while waiting for definitive diagnosis in patients with red flags 6
• Do not administer oxygen therapy indiscriminately; restrict its use to hypoxic patients only 7
• Avoid dismissing persistent symptoms thought to be referred pain, as they may indicate another concomitant critical disease 5
• For patients initially evaluated in an office setting, delayed transfer to the emergency department for troponin testing or other diagnostic testing should be avoided 2