What is the initial management for a patient presenting with chest pain in a ward setting?

Ward Management for Chest Pain

Immediate Actions (Within 10 Minutes)

All patients presenting with chest pain in a ward setting must receive a 12-lead ECG within 10 minutes of presentation, along with immediate administration of aspirin 160-325 mg (chewed), oxygen if hypoxic, sublingual nitroglycerin if blood pressure permits, and morphine for pain control. 1, 2

Critical First Steps

• Obtain 12-lead ECG within 10 minutes to identify ST-segment elevation myocardial infarction (STEMI), which requires immediate reperfusion therapy 1, 2, 3
• Administer aspirin 160-325 mg orally (chewed, not swallowed) unless contraindicated by active bleeding or known allergy 1, 2, 3
• Give sublingual nitroglycerin 0.3 mg every 5 minutes for up to 3 doses, but only if systolic blood pressure >90 mmHg and heart rate is 50-100 bpm 1, 3
• Administer morphine sulfate intravenously as the preferred analgesic, titrated to pain severity 1, 2, 3
• Provide oxygen by nasal prongs only if oxygen saturation is low (hypoxic patients); routine oxygen administration to non-hypoxic patients is not beneficial and may be harmful 1, 4
• Measure cardiac troponin immediately when acute coronary syndrome (ACS) is suspected 1, 2, 3

Vital Sign Assessment

• Check blood pressure, heart rate, respiratory rate, and oxygen saturation immediately 2, 3
• Place patient on continuous cardiac monitoring to detect arrhythmias 5
• Establish intravenous access for medication administration 5

Risk Stratification and History

High-Risk Features Requiring Immediate ED Transfer

Patients with any of the following features require immediate emergency department evaluation and should not be managed on a general ward: 1, 2

• Chest discomfort at rest for >20 minutes 1
• Hemodynamic instability (hypotension, shock) 1
• Recent syncope or presyncope 1
• Diaphoresis, tachypnea, tachycardia 2
• New crackles, S3 gallop, or new murmurs on examination 2

Critical History Elements to Obtain

• Pain characteristics: Retrosternal chest discomfort building gradually over minutes suggests ACS; sudden tearing/ripping pain radiating to back suggests aortic dissection 2
• Radiation pattern: Pain radiating to left arm, neck, or jaw is characteristic of ACS 2
• Associated symptoms: Dyspnea, nausea, diaphoresis, lightheadedness strongly suggest ACS 2
• Risk factors: Age, diabetes, hypertension, hyperlipidemia, smoking, family history of premature coronary artery disease 2

ECG Interpretation and Management Pathways

If STEMI Present (ST-elevation ≥1 mV in contiguous leads)

STEMI requires immediate reperfusion therapy with door-to-needle time for thrombolysis <30 minutes or first medical contact to balloon time <90 minutes. 1, 2

• Thrombolytic therapy saves 35 lives per 1000 when given within first hour versus 16 lives per 1000 when given 7-12 hours after symptom onset 2
• Pre-hospital thrombolysis reduces mortality by 17%, with 23 lives saved per 1000 per hour of earlier treatment 2
• Check contraindications to thrombolysis before administration 2

If ST-Depression or T-Wave Inversions Present

Treat according to non-ST-elevation ACS (NSTE-ACS) guidelines with antiplatelet therapy, anticoagulation, and risk stratification for timing of invasive management. 1, 3

• Do not administer thrombolytic therapy to patients without ST-elevation, as it is not beneficial 1
• Administer dual antiplatelet therapy: aspirin plus P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) 5, 6
• Initiate anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux 5

If Initial ECG Nondiagnostic

Obtain serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains high. 2, 3

• Consider supplemental leads V7-V9 to rule out posterior MI 3
• Measure serial cardiac troponins to detect myocardial injury (sensitivity >90%, specificity >95%) 5

Common Pitfalls to Avoid

Critical Diagnostic Errors

• Do not rely on nitroglycerin response as diagnostic for ACS, as esophageal spasm and other conditions may also respond to nitroglycerin 2, 3
• Do not assume young age excludes ACS, as it can occur in adolescents without risk factors 2
• Do not dismiss sharp, pleuritic pain as non-cardiac, since pericarditis and atypical ACS presentations can occur 2
• Do not delay transfer to ED for troponin testing in office or ward settings when ACS is suspected 2, 3

Special Population Considerations

• Women are at risk for underdiagnosis and often present with atypical symptoms including arm pain, jaw pain, epigastric discomfort, nausea, and fatigue rather than classic chest pain 2, 5
• Elderly patients (≥75 years) may present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 2

Differential Diagnosis Framework

Life-Threatening Causes to Rule Out

The three immediately life-threatening conditions are acute coronary syndrome, acute aortic syndromes, and pulmonary embolism, all of which must be identified within the first 10 minutes. 2

• Acute aortic dissection: Sudden-onset tearing pain with radiation to back; check for pulse deficits and blood pressure differentials between arms 2, 7
• Pulmonary embolism: Sudden dyspnea with pleuritic chest pain, particularly in patients with risk factors 1, 2
• Tension pneumothorax: Acute chest pain with respiratory distress, absent breath sounds, and hemodynamic compromise 8, 9

Additional Diagnostic Testing

• Chest radiograph to evaluate for cardiomegaly, pulmonary edema, pneumonia, or pneumothorax 3, 10
• D-dimer assay if pulmonary embolism is suspected, to determine need for further imaging 1, 10
• Basic metabolic panel and electrolytes 3

Medication Contraindications

Aspirin Contraindications

• Known aspirin allergy 2
• Active gastrointestinal bleeding 2

Nitroglycerin Contraindications

• Systolic blood pressure <90 mmHg 1, 2
• Heart rate <50 or >100 bpm 1, 2
• Recent use of phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) 1

Disposition Decisions

All patients with confirmed or suspected ACS must be admitted to a monitored setting (coronary care unit or telemetry) per standard guidelines. 5, 3

• Patients with STEMI require immediate transfer to a facility capable of percutaneous coronary intervention or administration of thrombolytics 1, 2
• Patients with NSTE-ACS require risk stratification using TIMI or GRACE score to guide intensity of therapy and timing of invasive management 5