What medications can help alleviate chest pain and palpitations of cardiac origin?

Medications for Cardiac Chest Pain and Palpitations

For acute cardiac chest pain, aspirin (250-500 mg chewable), morphine (IV titrated), nitrates (sublingual/IV), and beta-blockers (IV) form the cornerstone of immediate management, with specific drug selection based on ECG findings and hemodynamic status. 1, 2

Immediate Symptom Relief Medications

Pain Control

• Morphine (IV) is the preferred analgesic and should be administered even before ECG interpretation, as pain itself triggers sympathetic activation and worsens hemodynamics 1
• Dose must be titrated to individual pain severity and other concurrent medications 1
• Morphine is classified as mandatory equipment for pre-hospital cardiac emergencies 1

Nitrates for Ischemic Pain

• Nitrates should be used liberally for chest pain when myocardial ischemia is suspected, provided there is no bradycardia or hypotension 1, 2
• Short-acting sublingual nitrates (glyceryl trinitrate/isosorbide dinitrate) are recommended as first-line 2
• IV nitrates can be titrated according to blood pressure for ongoing symptom control 2
• Nitrates decrease ischemia and reduce cardiac filling pressures 1

Beta-Blockers for Both Pain and Palpitations

• IV beta-blockers are highly effective when myocardial ischemia is suspected, particularly with tachycardia and hypertension 1
• Beta-blockers control palpitations by managing tachyarrhythmias 1
• Recent evidence shows beta-blockers improve symptom control in pericarditis when added to anti-inflammatory therapy, reducing chest pain persistence from 14% to 4% at 3 weeks 3
• Beta-blockers are classified as highly recommended anti-hypertensive drugs for pre-hospital cardiac emergencies 1
• They may increase pain relief when added to morphine, though combination therapy carries more side-effects 4

Antithrombotic Therapy

Aspirin

• Fast-acting aspirin (250-500 mg, chewable or water-soluble) should be administered as soon as possible in suspected acute coronary syndrome 2
• Aspirin is recommended for treatment based on symptoms and signs in the pre-hospital setting 1
• Critical contraindication: Do not give aspirin if recent bleeding or subdural hematoma is present 5

Arrhythmia Management for Palpitations

Antiarrhythmic Medications

• Amiodarone is highly recommended for prevention of recurrent life-threatening arrhythmias 1, 2
• Adenosine (6-12 mg IV bolus) should be considered for selected cases of re-entrant supraventricular tachycardia causing palpitations 2
• Adenosine is classified as recommended medication for pre-hospital cardiac emergencies 1
• Electrical cardioversion is recommended for arrhythmias associated with hemodynamic instability rather than medication alone 2

Medication Selection Algorithm

For chest pain with suspected ACS:

1. Aspirin 250-500 mg (unless contraindicated) 2
2. Morphine IV (titrated for pain) 1
3. Nitrates sublingual/IV (if BP adequate) 1, 2
4. Beta-blockers IV (if tachycardic/hypertensive) 1

For palpitations with tachyarrhythmia:

1. Beta-blockers IV (first-line for rate control) 1
2. Adenosine 6-12 mg IV (for SVT) 2
3. Amiodarone (for life-threatening ventricular arrhythmias) 1, 2

For pericarditis with chest pain and palpitations:

1. Beta-blockers on top of anti-inflammatory therapy (target HR <75 bpm) 3
2. Pain relief with morphine as needed 1

Critical Caveats

Beta-Blocker Contraindications

• Avoid in severe bradycardia, heart block, or decompensated heart failure 1
• Verapamil (calcium channel blocker alternative) can cause excessive bradycardia and AV block when combined with beta-blockers 6
• The combination of beta-blockers and calcium channel blockers requires extreme caution with close monitoring 6

Nitrate Contraindications

• Do not administer if bradycardia or hypotension present 2
• Withhold in suspected aortic dissection 2

Aspirin Contraindications

• Recent bleeding is an explicit contraindication because mortality from rebleeding can equal or exceed cardiac mortality 5
• Recent subdural hematoma requires explicit neurosurgical clearance before restarting 5

Drug Interactions to Avoid

• Beta-blockers with calcium channel blockers (especially verapamil): Risk of excessive bradycardia, AV block, and complete heart block 6
• Verapamil with digoxin: Can increase digoxin levels by 50-75% in first week, risking toxicity 6
• Beta-blockers with disopyramide: Avoid within 48 hours before or 24 hours after verapamil 6