What is the management approach for a patient admitted with chest pain?

Management of Chest Pain in Admitted Ward Patients

Patients admitted to the ward with chest pain require immediate risk stratification based on ECG findings, cardiac biomarkers, and clinical features, with high-risk patients transferred to coronary care units and low-risk patients managed through observation protocols with serial troponin measurements and continuous monitoring. 1, 2

Immediate Assessment Upon Ward Admission

Initial Diagnostic Workup

• Obtain 12-lead ECG within 5 minutes of patient arrival to identify ST-segment elevation, depression, T-wave changes, or new left bundle branch block 1, 2
• Draw cardiac biomarkers immediately: troponin T or I and CK-MB mass on admission, with repeat measurement at 10-12 hours after symptom onset 1, 2
• Complete physical examination assessing consciousness, respiratory status, blood pressure, heart rate, body temperature, extremity temperature, and presence of sweating 1
• Obtain chest X-ray to exclude non-cardiac causes including pleuritis, pneumonia, pneumothorax, and intrathoracic tumors 1
• Measure arterial blood gases and complete blood count (Hb, RBC, WBC, platelets, CRP, creatinine) 1

Risk Stratification and Unit Assignment

High-Risk Features Requiring CCU Transfer

Patients with any of the following must be transferred to coronary care unit immediately as mortality is reduced by 53% with specialized care (6.8% vs 10.9% in general wards): 1

• Ongoing or recurrent chest pain with ischemic characteristics 1
• ST-segment depression or transient ST-segment elevation on ECG 1
• Elevated troponin levels (>0.1 μg/L) 1
• Left ventricular failure or hemodynamic instability (hypotension, pulmonary rales) 1
• Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
• Early post-infarction unstable angina 1
• Diabetes mellitus with acute symptoms 1

Low-to-Moderate Risk Ward Management

Patients without high-risk features can be safely managed in observation units for 9-12 hours with: 1

• Continuous cardiac rhythm monitoring with ST-segment monitoring capability 1, 2
• Serial ECG monitoring, particularly during any recurrent chest pain episodes 1
• Repeat troponin measurement at 6-12 hours after initial presentation 1

Immediate Medical Treatment

Pharmacologic Interventions

Administer aspirin 75-150 mg (or 250-500 mg chewable/water-soluble formulation) immediately unless contraindicated by hypersensitivity or major gastrointestinal intolerance 1, 2, 3

Provide pain relief without delay:

• Intravenous morphine titrated to pain severity, even before complete ECG interpretation 2
• Sublingual or intravenous nitrates for suspected myocardial ischemia (one tablet sublingual, may repeat every 5 minutes up to 3 doses) 2, 3
• Critical contraindications to nitrates: hypotension, bradycardia, recent use of phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil), or guanylate cyclase stimulators (riociguat) 3

Initiate anticoagulation for suspected ACS:

• Low-molecular-weight heparin or unfractionated heparin, particularly if troponin T >0.1 μg/L 1
• Consider clopidogrel in combination with aspirin (omit if CABG likely within 5 days) 1

Beta-blockers and calcium antagonists should be administered based on individual contraindications and tolerance 1

Diagnostic Workup for Non-ACS Causes

When Initial Cardiac Workup is Negative

If ECG is normal and initial biomarkers are negative but severe chest pain persists, evaluate for: 1

• Pulmonary embolism: pulmonary scintigraphy or spiral CT examination 1, 2
• Aortic dissection: transthoracic echocardiography initially, transesophageal echocardiography, CT, or MR scan if suspected 1, 2
• Pericarditis: clinical examination and echocardiography if hemodynamic disturbances or new murmurs present 1
• Pneumothorax: chest X-ray findings 1

Observation Period Management

Monitoring Protocol (6-12 Hours)

• Record 12-lead ECG during any recurrent chest pain and compare with baseline when symptoms resolve 1
• Monitor for hemodynamic instability: hypotension, development of pulmonary rales, changes in heart rate 1
• Assess for recurrent ischemia: repeat chest pain episodes, dynamic ST-segment changes 1
• Perform transthoracic echocardiography to assess left ventricular function and exclude other cardiovascular causes if indicated 1

Pre-Discharge Evaluation for Low-Risk Patients

Exercise stress testing before discharge is optional but can reveal severe myocardial ischemia at low workload in appropriately selected patients 1

• Only 40% of patients may be eligible for early discharge pathways 1
• Stress testing with imaging (echocardiography or nuclear) is preferred over standard exercise testing 1
• Among low-risk patients with negative 9-12 hour observation, cardiac event rates are <2% 1

Special Considerations

Cocaine-Associated Chest Pain

Only 0.7-6% of cocaine-associated chest pain represents true MI, but high-risk features require standard ACS management: 1

• Admit patients with ST-segment elevation/depression ≥1 mm, elevated cardiac markers, recurrent pain, or hemodynamic instability 1
• Among admitted high-risk cocaine users, 24% have MI and 24% have unstable angina 1
• Avoid beta-blockers in acute cocaine intoxication due to unopposed alpha-adrenergic stimulation 1
• Benzodiazepines are appropriate for symptom management (used in 30% of cases) 1

Common Pitfalls to Avoid

• Do not delay pain relief or hemodynamic stabilization while awaiting complete diagnostic workup 1
• Do not rely solely on initial troponin: 10-12 hour repeat is essential as initial values may be falsely negative 1
• Do not discharge patients with normal ECG and negative initial biomarkers without completing observation period and repeat troponin 1
• Do not administer nitrates to patients taking erectile dysfunction medications within 24-48 hours due to severe hypotension risk 3
• Do not assume chest pain is cardiac: only 10-15% of chest pain presentations represent acute MI, requiring systematic exclusion of life-threatening non-cardiac causes 1