From the Guidelines
Substernal chest pain during rehabilitation treatments requires immediate attention and assessment, and the activity should be stopped immediately to evaluate for signs of cardiac distress. If a patient experiences substernal chest pain during rehab, evaluate for signs of cardiac distress including radiation to arm/jaw, shortness of breath, nausea, or diaphoresis 1. For acute management, have the patient rest, administer aspirin 325mg if available and not contraindicated, and activate emergency services if pain persists beyond a few minutes or is accompanied by concerning symptoms. Nitroglycerin 0.4mg sublingual can be given if prescribed and available, repeating every 5 minutes for up to three doses if needed. The importance of monitoring and managing cardiac rehabilitation is highlighted in a study published in Nature Reviews Cardiology, which emphasizes the role of cardiac rehabilitation in improving cardiovascular outcomes 1. For ongoing rehabilitation, patients with known cardiac conditions should be monitored with vital signs before, during, and after exercise, maintain exercise intensity below their anginal threshold (typically 60-80% of max heart rate), and gradually progress activity levels. Patients should be educated to report chest discomfort immediately and distinguish between cardiac pain and musculoskeletal discomfort. This approach is critical because substernal chest pain may indicate myocardial ischemia due to increased oxygen demand during exercise that exceeds coronary blood flow capacity, particularly in patients with coronary artery disease. Key aspects of symptoms that suggest their origin in terms of probable ischemia include quality, location, radiation, and provoking and relieving factors, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. Some key points to consider in the management of substernal chest pain during rehabilitation include:
- Stopping the activity immediately and evaluating for signs of cardiac distress
- Administering aspirin and nitroglycerin as needed
- Monitoring vital signs and exercise intensity
- Educating patients to report chest discomfort immediately
- Gradually progressing activity levels to avoid exacerbating cardiac conditions.
From the FDA Drug Label
Among patients treated with metoprolol, there were comparable reductions in 3-month mortality for those treated early (≤ 8 hours) and those in whom treatment was started later Significant reductions in the incidence of ventricular fibrillation and in chest pain following initial intravenous therapy were also observed with metoprolol and were independent of the interval between onset of symptoms and initiation of therapy The answer to the question about substernal chest pain in rehab treatments is that metoprolol has been shown to reduce chest pain in patients with myocardial infarction, as evidenced by significant reductions in the incidence of chest pain following initial intravenous therapy 2.
- Key points:
- Metoprolol reduces chest pain in patients with myocardial infarction
- The reduction in chest pain is independent of the interval between onset of symptoms and initiation of therapy
- Metoprolol is effective in reducing 3-month mortality in patients with suspected or definite myocardial infarction
From the Research
Substernal Chest Pain in Rehab Treatments
- Substernal chest pain is a common symptom of angina pectoris, which is defined as chest pain, pressure, or discomfort that is typically exacerbated by exertion and/or emotional stress, lasts greater than 30 to 60 seconds, and is relieved by rest and nitroglycerin 3.
- The management of angina includes pharmacologic therapy, such as β-blockers, nitrates, calcium channel blockers, and the late sodium current blocker ranolazine, as well as revascularization in certain high-risk individuals 3.
- For patients with refractory angina, which is defined as the persistence of symptoms despite conventional therapies, spinal cord stimulation treatment is a viable option 4.
- In addition to these treatments, lifestyle modification and pharmacological management are considered as conservative treatments for angina 4.
- It is also important to note that non-cardiac chest pain, such as oesophageal disorders, musculoskeletal problems, and psychological disorders, can also cause substernal chest pain, and a thorough evaluation is necessary to determine the underlying cause of the pain 5.
Treatment Options
- Aspirin is a class I guideline recommended medical treatment for acute coronary syndrome, and self-administration of aspirin in acute chest pain might be beneficial 6.
- Oxygen, aspirin, nitrates, and opiates are commonly used in the prehospital treatment of chest pain of suspected cardiac origin 7.
- Prehospital 12-Lead ECGs are used in the majority of agencies, and regionalized care for STEMI patients is also common 7.
- Enhanced external counterpulsation, transmyocardial revascularization, and stem cell therapy are also treatment options for refractory angina 3.