From the Guidelines
For chest pain, the medical decision making (MDM) involves assessing the severity, potential causes, and appropriate management, with a focus on early identification or exclusion of life-threatening causes, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The MDM process for chest pain should consider both cardiac and non-cardiac causes, and involve a rapid clinical determination of the likelihood risk of obstructive CAD, as well as early risk stratification for the risk of cardiovascular events 1.
- Key components of the MDM process include:
- Evaluating the patient's history, physical examination, and diagnostic tests, such as ECG, cardiac enzymes, and chest X-ray
- Considering the use of high-sensitivity troponins for establishing a biomarker diagnosis of acute myocardial infarction 1
- Using clinical decision pathways for chest pain in the emergency department and outpatient settings 1
- Identifying patients most likely to benefit from further testing, such as those at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease 1
- Estimating risk for coronary artery disease and adverse events using evidence-based diagnostic protocols 1 The most recent and highest quality study, the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline, recommends a structured approach to the evaluation and diagnosis of chest pain, with a focus on early identification or exclusion of life-threatening causes, and emphasizes the importance of shared decision-making and patient-centered care 1. For cardiac causes like acute coronary syndrome, treatment may involve aspirin, nitroglycerin, and serial troponins, as well as additional medications like P2Y12 inhibitors, anticoagulation, and beta-blockers if ACS is confirmed 1.
- Non-cardiac causes, such as GERD, may be treated with medications like proton pump inhibitors The complexity of MDM depends on the risk stratification, with low-risk patients potentially managed outpatient with follow-up, and high-risk patients requiring admission for further monitoring and treatment 1. This approach balances immediate symptom relief with diagnostic evaluation to identify and treat the underlying cause of chest pain, and is supported by the available evidence, including the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1 and other studies 1.
From the FDA Drug Label
Metoprolol is a beta 1-selective (cardioselective) adrenergic receptor blocker. By blocking catecholamine-induced increases in heart rate, in velocity and extent of myocardial contraction, and in blood pressure, metoprolol reduces the oxygen requirements of the heart at any given level of effort, thus making it useful in the long-term management of angina pectoris
- MDM for Chest Pain:
From the Research
MDM for Chest Pain
The following are key points to consider when evaluating a patient with chest pain:
- Chest pain is a common presenting complaint in the emergency department, but only a small minority of patients are diagnosed with acute coronary syndrome (ACS) 3
- ACS presentations can be atypical, and their workups are often prolonged and costly 3
- Several decision aids have been developed to risk-stratify patients and better direct the workup and care given, including:
- Thrombolysis in myocardial infarction (TIMI) risk score
- Global Registry of Acute Coronary Events (GRACE) scores
- Asia-Pacific Evaluation of Chest Pain Trial (ASPECT)
- Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT)
- North American Chest Pain Rule (NACPR)
- History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score 3
- Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw 4
- Electrocardiography changes that predict ACS include ST depression, ST elevation, T-wave inversion, or presence of Q waves 4
- Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation ACS 4
- Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization, as well as initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy 4
- Recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED 5
- There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI 5