What is the initial management of chest pain?

Initial Management of Chest Pain

The initial management of chest pain requires obtaining a 12-lead ECG within 10 minutes of patient presentation, administering aspirin (250-500mg) if acute coronary syndrome is suspected, providing pain relief, and assessing for high-risk features that warrant immediate intervention. 1, 2

Immediate Assessment and Triage

• Obtain a 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 2, 1
• Draw blood samples for cardiac biomarkers (troponin T or I, CK-MB mass) on admission and at 10-12 hours after symptom onset 2, 1
• Assess vital signs, level of consciousness, and signs of hemodynamic instability (heart rate <40 or >100/min, systolic BP <100 or >200 mmHg, cold extremities) 1
• Evaluate for high-risk features: ongoing pain, associated symptoms (sweating, nausea, vomiting), and ECG changes 1, 3
• Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby 3

Immediate Interventions

• Administer fast-acting aspirin (250-500 mg, chewable or water-soluble) as soon as possible for suspected ACS 1, 4, 5
• Provide pain relief with intravenous morphine titrated according to pain severity 1
• Administer sublingual nitroglycerin (one tablet dissolved under the tongue) for suspected myocardial ischemia, which may be repeated approximately every 5 minutes until relief is obtained 6
• If pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than typically experienced, seek prompt medical attention 6
• Correct and stabilize any hemodynamic changes without delay 2

Management Based on ECG Findings

For STEMI:

• Initiate immediate reperfusion therapy (thrombolysis or primary PCI) within 30 minutes of diagnosis 2, 1
• Transfer directly to cardiac catheterization laboratory if PCI facilities are available 1

For NSTE-ACS:

• Consider an antithrombotic regimen including aspirin, P2Y12 inhibitor loading dose, and anticoagulation with enoxaparin or unfractionated heparin 2, 7
• Patients with cardiogenic shock, life-threatening arrhythmias, and persistent ischemia despite initial management should be managed similarly to STEMI patients 2

For Normal ECG:

• Perform careful history, clinical examination, and additional laboratory examinations when ECG and biochemical markers are normal but the patient has severe chest pain 2
• Consider other life-threatening conditions such as pulmonary embolism, aortic dissection, acute pericarditis, and pneumothorax 2, 8

Risk Stratification and Disposition

• Assess for high-risk features: recurrent ischemia, elevated troponin levels, hemodynamic instability, major arrhythmias, and diabetes mellitus 1
• Consider admission to coronary care unit for patients with ongoing pain, ischemic ECG changes, positive troponin, left ventricular failure, or hemodynamic abnormalities 2
• Observe low-to-moderate risk patients in chest pain units for 10-12 hours after symptom onset 1

Special Considerations

Nitroglycerin Administration:

• Patient should sit down when taking nitroglycerin sublingual tablets and use caution when standing up to prevent falling due to lightheadedness or dizziness 6
• Do not use nitroglycerin with medications for erectile dysfunction (e.g., sildenafil, tadalafil, vardenafil) as this may lead to extreme hypotension 6
• Common side effects include headache, dizziness, weakness, and flushing 6

Suspected Aortic Dissection:

• Consider aortic dissection in patients with chest, abdominal, or back pain, syncope, unexplained hypotension, and focal neurological disorders 2
• Use the Aortic Dissection Detection Score to assess probability (high risk with score >0) 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 3
• Do not delay treatment while waiting for definitive diagnosis in patients with red flags 3
• Avoid private vehicle transport for patients with chest pain, as approximately 1 in 300 chest pain patients transported by private vehicle goes into cardiac arrest en route 3
• Be aware that elderly patients or those with diabetes may present atypically and require heightened vigilance 3