What is the management approach for a patient with severe chest pain?

Management of Severe Chest Pain

Patients with severe chest pain require immediate assessment and management with a focus on identifying and treating life-threatening conditions, particularly acute coronary syndromes. 1

Immediate Actions (First 5-10 Minutes)

• Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby, and perform ECG within 10 minutes of arrival 1
• Obtain vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature) and a focused history of the chest pain (onset, character, radiation, associated symptoms) 2
• Administer aspirin 250-500mg if not contraindicated (no history of allergy or recent bleeding) 1
• Establish IV access and draw blood for cardiac biomarkers (troponin T or I), complete blood count, and basic chemistry 2
• Provide supplemental oxygen if oxygen saturation is low (<94%) 2
• Administer pain relief: morphine given intravenously is the preferred drug for severe pain, titrated according to severity 2
• Consider sublingual nitroglycerin for suspected cardiac chest pain if no contraindications (hypotension, recent phosphodiesterase inhibitor use) 3

Diagnostic Evaluation

• ECG interpretation is the most critical initial diagnostic tool - look for ST-segment elevation/depression, T-wave inversions, or other abnormalities 2, 4
• Obtain chest X-ray to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 2
• Perform bedside echocardiography if available, particularly if hemodynamic instability or new murmurs are present 2
• Consider additional imaging based on clinical suspicion:
  • CT angiography if aortic dissection is suspected 2
  • Pulmonary scintigraphy or spiral CT if pulmonary embolism is suspected 2

Risk Stratification

High-Risk Features (Require Immediate Intervention)

• Recurrent ischemia (ongoing pain or dynamic ECG changes) 2
• Elevated troponin levels 2
• Hemodynamic instability (hypotension, pulmonary edema) 2
• Major arrhythmias (ventricular tachycardia, ventricular fibrillation) 2
• ECG showing ST-segment elevation or new left bundle branch block 2

Management Based on Risk Assessment

For High-Risk Patients (Suspected Acute Coronary Syndrome)

• Continue aspirin therapy 2
• Administer low molecular weight heparin or unfractionated heparin 2
• Consider beta-blockers if no contraindications (particularly with tachycardia or hypertension) 2
• For ST-elevation MI: Activate cardiac catheterization lab for primary PCI or administer thrombolytics if PCI not available within 120 minutes (door-to-needle time should be under 30 minutes) 2
• For non-ST elevation ACS with high-risk features: Plan for early invasive strategy with coronary angiography within 48 hours 2

For Suspected Non-Cardiac Causes

• Aortic dissection: Control blood pressure, urgent surgical consultation 2
• Pulmonary embolism: Anticoagulation, consider thrombolysis if hemodynamically unstable 2
• Pneumothorax: Needle decompression for tension pneumothorax, chest tube placement 2
• Acute pericarditis: NSAIDs, colchicine, avoid anticoagulation 5

Admission Criteria

• Patients with ongoing chest pain should be admitted to a specialized coronary care unit or intensive care unit without delay 2
• Priority for CCU admission should be given to those with:
  • Severe continuing pain 2
  • Ischemic ECG changes 2
  • Positive troponin test 2
  • Left ventricular failure or hemodynamic abnormalities 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
• Do not delay treatment while waiting for definitive diagnosis in patients with red flags 1
• Do not discharge patients with normal ECG without further evaluation - consider serial troponin measurements (6-12 hours apart) 2
• Do not transport high-risk patients by private vehicle - approximately 1 in 300 chest pain patients transported by private vehicle goes into cardiac arrest en route 1
• Be aware that elderly patients or those with diabetes may present with atypical symptoms 1

Special Considerations

• For patients with normal ECG but persistent symptoms, consider serial ECGs (every 15-30 minutes) and troponin measurements (6-12 hours apart) 2
• In patients with sickle cell disease, consider acute chest syndrome as a potential cause of chest pain 6
• Consider musculoskeletal causes of chest pain (Tietze's syndrome, fibrositis) only after excluding life-threatening conditions 7
• For pleuritic chest pain, pulmonary embolism should be considered as it is the most common serious cause 5