Management of Elderly Male with Continuous Chest Pain and History of CABG
Immediate Action Required
This patient requires immediate transfer to the emergency department by EMS for evaluation of acute coronary syndrome (ACS), given continuous chest pressure in an elderly male with prior CABG 20 years ago and elevated blood pressure readings. 1, 2
Do not transport by personal automobile—call emergency services immediately. 2
Critical Assessment Within 10 Minutes of ED Arrival
ECG Evaluation
- Obtain and interpret 12-lead ECG within 10 minutes of first medical contact to identify ST-elevation myocardial infarction (STEMI), new ST-segment depression, or new left bundle branch block. 1
- If initial ECG is non-diagnostic but symptoms persist, perform serial ECGs at 15-30 minute intervals during the first hour. 1
- Consider supplemental leads V7-V9 if posterior infarction is suspected. 1
Cardiac Biomarkers
- Draw cardiac troponin (cTnI or cTnT) immediately upon arrival—results should be available within 60 minutes. 1
- Repeat troponin measurement at 3 hours after symptom onset if high-sensitivity assays are used, or at 3-6 hours for standard assays. 1
- Do not wait for troponin results to initiate treatment if ECG shows acute ischemic changes. 1
Vital Signs and Physical Examination
- Monitor blood pressure, heart rate, respiratory rate, and oxygen saturation continuously. 1
- Assess for signs of heart failure (basal rales, third heart sound, jugular venous distension) or hemodynamic instability. 1
- Examine for autonomic activation (pallor, sweating, cold extremities). 1
Immediate Medical Management
Antiplatelet Therapy
- Administer aspirin 150-300 mg non-enteric formulation immediately unless contraindicated. 1, 2
- Add P2Y12 inhibitor (ticagrelor or clopidogrel) loading dose once ACS diagnosis appears likely. 1
Anticoagulation
- Initiate parenteral anticoagulation with one of the following: 1
- Fondaparinux 2.5 mg subcutaneously daily (preferred for conservative strategy)
- Enoxaparin 1 mg/kg subcutaneously twice daily
- Unfractionated heparin IV bolus 60-70 IU/kg (maximum 5000 IU) followed by infusion of 12-15 IU/kg/h (maximum 1000 IU/h) titrated to aPTT 1.5-2.5 times control
Symptom Relief
- Administer sublingual or IV nitroglycerin for ongoing chest pain if no contraindications (hypotension, bradycardia, right ventricular infarction). 1
- Give IV opioids (morphine 4-8 mg with additional 2 mg doses every 5-15 minutes) for pain relief if nitroglycerin is insufficient. 1
- Avoid intramuscular injections. 1
Beta-Blocker Therapy
- Administer oral beta-blocker if patient is tachycardic or hypertensive without signs of heart failure, hypotension, or bradycardia. 1
- Do not abruptly discontinue beta-blockers in patients with coronary artery disease, as this can precipitate severe angina exacerbation, myocardial infarction, or ventricular arrhythmias. 3
Risk Stratification and Admission
High-Risk Features Requiring CCU Admission
- Admit immediately to coronary care unit or chest pain unit if any of the following are present: 1
- Ongoing chest pain despite initial treatment
- Ischemic ECG changes (ST-segment deviation, T-wave inversion)
- Positive troponin test
- Hemodynamic instability or left ventricular failure
- History of prior CABG with recurrent symptoms (this patient qualifies)
Mortality Benefit of Specialized Care
- Patients treated in coronary care units have 53% lower mortality compared to general medical wards (6.8% vs 10.9% age-adjusted 30-day mortality). 1
Timing of Invasive Strategy
Immediate Angiography (<2 hours) Indicated If:
- Hemodynamic instability or cardiogenic shock 1
- Recurrent or ongoing chest pain refractory to medical treatment 1
- Life-threatening arrhythmias or cardiac arrest 1
Early Angiography (<24 hours) Indicated If:
- Elevated troponin levels 1
- Dynamic ST-segment or T-wave changes 1
- History of prior CABG with recurrent symptoms 1
Radial Access Preferred
- Use radial artery access for coronary angiography to reduce bleeding complications. 1
Critical Pitfalls to Avoid
Do Not Delay Transfer
- Never delay emergency department transfer to obtain troponin testing in an outpatient setting—this causes harmful delays in diagnosis and treatment. 4
- The door-to-needle time for fibrinolytic therapy (if indicated) should be kept under 30 minutes. 1
Do Not Dismiss Atypical Features
- Do not assume chest pain is non-cardiac based on atypical characteristics alone—22% of patients with sharp/stabbing pain and 13% with pleuritic pain had acute ischemia in the Multicenter Chest Pain Study. 1
- Physical examination contributes almost nothing to diagnosing myocardial infarction unless shock is present. 4
Do Not Rely on Nitroglycerin Response
- Relief of chest pain with nitroglycerin is not predictive of ACS and should not be used to rule out cardiac etiology. 1
Do Not Abruptly Stop Beta-Blockers
- Gradual dose reduction over 1-2 weeks is required when discontinuing beta-blockers in patients with coronary artery disease to avoid rebound ischemia. 3
Special Considerations for This Patient
Prior CABG Status
- Patients with prior CABG presenting with chest pain have higher risk and warrant aggressive evaluation even with normal initial ECG. 5, 6
- Graft occlusion or native vessel disease progression is common 20 years post-CABG. 7, 6, 8
- Only 54% of CABG patients remain free from chest pain at 10 years post-surgery. 8
Blood Pressure Management
- Current BP of 132/68 mmHg is acceptable, but previous readings in 140s-150s suggest hypertension that may have contributed to increased myocardial oxygen demand. 1
- Beta-blockers serve dual purpose of controlling blood pressure and reducing myocardial oxygen consumption. 1
Pattern of Symptoms
- Progression from transient chest pain yesterday to continuous pain today represents crescendo angina—a high-risk unstable angina pattern requiring urgent intervention. 1