What is the best course of action for a male patient with acute shortness of breath and chest tightness, possibly with a history of cardiovascular or respiratory issues?

Management of Male Patient with Acute Shortness of Breath and Chest Tightness

Immediately activate emergency protocols with continuous cardiac monitoring, obtain a 12-lead ECG within 10 minutes, and prepare for potential acute coronary syndrome or acute heart failure while simultaneously assessing cardiopulmonary stability. 1, 2

Immediate Triage and Stabilization (First 10 Minutes)

Determine cardiopulmonary stability as the critical first step – patients with respiratory failure or hemodynamic compromise require immediate triage to a location with respiratory and cardiovascular support capability. 1

Essential Monitoring (Within Minutes of Contact)

• Establish continuous monitoring immediately: pulse oximetry, blood pressure, respiratory rate, and continuous ECG 1, 3
• Assess mental status using AVPU (alert, visual, pain, or unresponsive) as an indicator of hypoperfusion 1
• Measure oxygen saturation to guide oxygen therapy decisions 3

Oxygen Therapy Protocol

• Administer oxygen if SpO₂ <90% (Class I recommendation) 3
• For SpO₂ 90-94%, use clinical judgment considering respiratory work and difficulty 3
• Target SpO₂ >90% but avoid hyperoxia, which can cause vasoconstriction and reduce cardiac output 3
• Do NOT routinely give oxygen if SpO₂ is adequate, as there is insufficient evidence for routine supplementary oxygen in chest discomfort 1

Critical Diagnostic Workup (Simultaneous with Stabilization)

Cardiac Evaluation (Rule Out ACS/MI)

Obtain 12-lead ECG within 10 minutes of arrival and place on continuous cardiac monitoring with defibrillation capability. 2 The ECG is necessary to exclude ST-elevation myocardial infarction, though it is rarely normal and rarely diagnostic in acute presentations. 1

Draw cardiac biomarkers (troponin) at presentation with planned repeat at 6 hours, as a single measurement can miss NSTEMI. 2 This is critical because male patients with cardiovascular risk factors may present with atypical symptoms. 2

Check complete blood count, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, and fasting glucose. 2

Respiratory/Heart Failure Evaluation

Obtain chest radiography to evaluate for pulmonary venous congestion, pleural effusions, interstitial or alveolar edema, and to rule out alternative causes like pneumonia. 1 However, recognize that in nearly 20% of patients the chest X-ray may be normal, limiting overall sensitivity. 1

Consider bedside thoracic ultrasound for signs of interstitial edema if expertise is available – this may be equally or more informative than chest X-ray and saves time. 1 B-lines (vertical, long, well-defined artifacts) indicate pulmonary edema. 1

Immediate echocardiography is mandatory if hemodynamic instability or cardiogenic shock is present. 1 In stable patients, echocardiography should be performed after stabilization, especially with de novo disease. 1

Blood Pressure-Based Treatment Algorithm

If Systolic Blood Pressure >110 mmHg (Hypertensive Acute Heart Failure)

Initiate IV vasodilators (nitrates) as first-line therapy along with diuretics. 3

Nitroglycerin administration options:

• Spray: 400 mcg (2 puffs) every 5-10 minutes while monitoring blood pressure 3
• Oral: isosorbide dinitrate 1-3 mg 3
• IV: nitroglycerin 20 mcg/min, increasing to 200 mcg/min, or isosorbide dinitrate 1-10 mg/h with careful blood pressure monitoring 3

Loop diuretics (furosemide):

• Initiate within 60 minutes of presentation 3
• Dose: 40-80 mg IV if not taking diuretics, or twice the daily oral dose if already on diuretics 3
• Target: urinary sodium output ≥50-70 mmol/L within 2 hours and urine output ≥100-150 mL/hour within 6 hours 3

Consider morphine 3 mg IV boluses (can be repeated) if severe dyspnea and anxiety are present (Class IIb recommendation). 3 However, use morphine with extreme caution as respiratory depression is the primary risk, especially in elderly or debilitated patients. 4

Consider non-invasive ventilation (CPAP or BiPAP) if respiratory rate >25/min or SpO₂ <90% to reduce respiratory difficulty and decrease intubation rate. 3

If Systolic Blood Pressure <110 mmHg (Normotensive/Hypotensive)

Administer IV diuretics at lower initial doses and avoid or use vasodilators with extreme caution. 3

Close monitoring for hypotension is essential – assess volume status carefully as dehydration or overdiuresis can cause hypotension and symptoms without representing ACS. 2

If cardiogenic shock (SBP <90 mmHg), immediate echocardiography is mandatory and patient requires ICU/CCU level care. 1

Respiratory Support Escalation

Non-Invasive Ventilation

CPAP is simpler and preferred in the prehospital setting, requiring no ventilator or special training. 3

BiPAP is preferred in patients with significant hypercapnia, especially those with COPD. 3

Intubation Criteria

Intubate if respiratory failure occurs with:

• PaO₂ <60 mmHg
• PaCO₂ >50 mmHg
• pH <7.35 that cannot be managed non-invasively 3

Use midazolam for intubation as it has fewer cardiac side effects than propofol, which can induce hypotension. 3

Critical Pitfalls to Avoid

The biggest error is attributing all symptoms to either cardiac or respiratory causes exclusively – both must be evaluated simultaneously in this presentation. 2 Chest tightness and shortness of breath can represent acute coronary syndrome, acute heart failure, pulmonary embolism, pneumonia, or pneumothorax. 5

Do not delay treatment waiting for complete diagnostic workup – the "time-to-treatment" concept is important, and appropriate therapy should be initiated as early as possible based on clinical presentation and blood pressure. 1

Avoid placing objects in the patient's mouth if seizure occurs, as this may cause dental damage or aspiration. 1

Do not administer morphine to patients with respiratory depression, acute/severe asthma, or suspected paralytic ileus – these are contraindications. 4

Rapid IV morphine administration may result in chest wall rigidity – administer slowly and have naloxone and resuscitative equipment immediately available. 4

Disposition and Transfer

Rapid transfer to the nearest hospital with cardiology department and/or CCU/ICU capability should be pursued. 1 Patients with signs of shock, pulmonary congestion, heart rate >100 bpm, and systolic blood pressure <100 mmHg should ideally be triaged to facilities capable of cardiac catheterization and revascularization. 1

On arrival in the ED/CCU/ICU, initial clinical examination, investigations, and treatment should be started immediately and concomitantly. 1