From the Guidelines
The management of a 65-year-old man with chest pain and shortness of breath should prioritize immediate evaluation and treatment for potentially life-threatening conditions, with a focus on administering aspirin 162 to 324 mg as soon as possible, as recommended by the 2024 American Heart Association guidelines 1. The patient's symptoms, including chest pain and shortness of breath, necessitate a comprehensive assessment to identify potential cardiac causes. Key considerations include:
- Assessing vital signs and obtaining an ECG, chest X-ray, cardiac enzymes (troponin), complete blood count, basic metabolic panel, and arterial blood gases if available
- Administering oxygen to maintain saturation above 94% and establishing IV access
- Considering the administration of aspirin, as it has been shown to improve survival in patients with myocardial infarction, with a low rate of major complications associated with its administration 1
- Evaluating the patient for other life-threatening conditions, such as pulmonary embolism, heart failure, and aortic dissection, and initiating appropriate treatment, including anticoagulation with heparin or low molecular weight heparin for suspected pulmonary embolism, and furosemide 40mg IV for heart failure The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain emphasizes the importance of rapid initiation of optimal management in patients with life-threatening conditions, as well as deliberate therapy for those with less critical illness 1. Given the potential for significant morbidity and mortality associated with delayed treatment, prompt intervention is critical, and the patient should be monitored continuously and transferred to a higher level of care if unstable.
From the FDA Drug Label
Nitroglycerin is a type of medicine known as an organic nitrate and is a vasodilating agent. It is used to treat a type of chest pain called angina. Angina is a pain or discomfort that keeps coming back when part of your heart does not get enough blood Nitroglycerin sublingual tablets can relieve this pain. One tablet should be dissolved under the tongue or in the oral cavity at the first sign of chest pain. The dose may be repeated approximately every 5 minutes, until the chest pain is relieved If the pain persists after a total of 3 tablets in a 15-minute, period, or is different than you typically experience, call your doctor or seek emergency help.
The management of a 65-year-old man with chest pain and shortness of breath may include the use of nitroglycerin sublingual tablets to relieve angina pain. The patient should take one tablet under the tongue or in the oral cavity at the first sign of chest pain, and the dose may be repeated every 5 minutes until the pain is relieved, up to a total of 3 tablets in a 15-minute period. If the pain persists, the patient should call their doctor or seek emergency help 2.
Key considerations:
- The patient should sit down when taking nitroglycerin sublingual tablets and use caution when standing up to avoid lightheadedness or dizziness.
- The patient should not take nitroglycerin sublingual tablets if they are allergic to organic nitrates or have certain medical conditions, such as very recent heart attack, severe anemia, or increased pressure in the head.
- The patient should not take nitroglycerin sublingual tablets with certain medications, such as drugs for erectile dysfunction or guanylate cyclase stimulators.
From the Research
Management of Chest Pain and Shortness of Breath in a 65-Year-Old Man
The management of a 65-year-old man with chest pain and shortness of breath involves several steps, including:
- Initial assessment and diagnosis to determine the underlying cause of the symptoms
- Administration of medications to relieve chest pain and prevent further complications
- Potential use of invasive procedures to restore blood flow to the heart
Medications and Therapies
The following medications and therapies may be recommended:
- Aspirin, unless contraindicated, to reduce the risk of acute coronary syndrome 3, 4
- A second antiplatelet agent, such as clopidogrel, ticagrelor, or prasugrel, for dual antiplatelet therapy 3
- Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 3
- Proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use 3
- Statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine to relieve chest pain and improve outcomes 3
- Oxygen therapy to alleviate shortness of breath
Invasive Procedures
Invasive procedures, such as:
- Percutaneous coronary intervention (PCI) with stent placement, may be recommended for patients with ST-segment elevation myocardial infarction 3
- Coronary artery bypass grafting (CABG) may be necessary to reestablish coronary artery flow in certain patients 3
- Fibrinolytic therapy may be used as an alternative to PCI in certain situations 3
Considerations in Elderly Patients
Elderly patients, such as the 65-year-old man in question, are at increased risk for serious morbidity and mortality from life-threatening causes of chest pain 5