How to manage chest pain in an adult with potential risk factors for cardiovascular disease in a resource-poor setting?

Managing Chest Pain in Resource-Poor Settings

In resource-poor settings, immediately administer chewable aspirin 300-350 mg and obtain a 12-lead ECG within 10 minutes; if STEMI is confirmed, proceed with thrombolysis using streptokinase as the primary reperfusion strategy when PCI is unavailable, followed by stabilization with dual antiplatelet therapy, high-dose statins, beta-blockers, and ACE inhibitors. 1

Immediate Recognition and Initial Actions

Symptom Recognition and Community Education

• Public education about chest pain symptoms is critically important in resource-limited settings, as delayed presentation is a major barrier to effective treatment 1
• Train patients and communities to recognize acute chest pain, pressure, or discomfort as requiring immediate medical attention 1
• Emphasize the "time is muscle" concept to overcome denial and delays in seeking care 1

First Contact Management (Level 1-2 Facilities)

• Obtain a 12-lead ECG immediately upon patient presentation - this is the single most important diagnostic tool and should be considered standard of care even in the most basic facilities 1
• Administer chewable or soluble aspirin 300-350 mg stat unless contraindicated by known allergy or active bleeding 1
• If ECG is unavailable, use clinical judgment and refer urgently to higher-level facilities - it is safer to assume ST-elevation with appropriate chest pain represents coronary occlusion 1
• Repeat ECG at 15-minute intervals for the next hour if initial ECG is nondiagnostic but clinical suspicion remains high 1

Risk Stratification Without Advanced Resources

High-Risk Features Requiring Immediate Action

• Prolonged rest pain >20 minutes with diaphoresis, dyspnea, nausea, or syncope indicates high-risk acute coronary syndrome 2, 3
• Hemodynamic instability, ongoing chest pain, or electrical instability (arrhythmias) mandate urgent treatment 1
• Prior myocardial infarction, known coronary disease, age >70 years, diabetes mellitus, or renal insufficiency increase cardiac risk 2

ECG-Based Decision Making

• ST-segment elevation ≥1 mm in contiguous leads confirms STEMI and requires immediate reperfusion therapy 1
• ST-segment depression or T-wave inversions suggest NSTEMI/unstable angina 1
• Normal ECG does not exclude acute coronary syndrome - repeat ECG after 90 minutes 1

Reperfusion Strategy in Resource-Limited Settings

Thrombolysis as Primary Strategy (Level 3 Facilities)

Thrombolytic therapy with streptokinase is the cornerstone of STEMI management in resource-poor settings where PCI is unavailable or delayed 1

Thrombolysis Protocol:

• Check absolute and relative contraindications before initiating fibrinolytic therapy 1
• Streptokinase is the most cost-effective thrombolytic agent available in low- and middle-income countries 1
• Administer thrombolysis as per local protocol for confirmed STEMI 1
• Door-to-needle time should be <30 minutes when thrombolysis is the chosen strategy 1

Post-Thrombolysis Management:

• In resource-constrained situations, only high-risk patients should be referred for catheterization after successful lysis - these include patients with hemodynamic/electrical instability, left ventricular dysfunction, and elderly patients 1
• Low-risk patients require risk stratification with early treadmill testing and referral only for inducible ischemia 1
• This selective approach reduces costs while maintaining outcomes in resource-limited settings 1

When PCI is Contraindicated or Unavailable

• If thrombolysis is contraindicated, stabilize and transfer within 3-24 hours to higher-level facility if possible 1
• Bare metal stents may be the default option due to cost constraints, though drug-eluting stents should be considered for smaller vessels (<3.0 mm), longer lesions (>20 mm), and diabetic patients 1

Essential Medical Therapy (All Patients)

Immediate Medications

• Aspirin 300-350 mg stat (chewable/soluble) 1
• High-dose statin: Atorvastatin 80 mg or Rosuvastatin 40 mg 1
• Clopidogrel as part of dual antiplatelet therapy 1
• Beta-blockers for protective drug therapy 1
• ACE inhibitors for cardioprotection 1

Medications to Avoid or Use Cautiously

• Do not use nitroglycerin response as a diagnostic tool - esophageal spasm and other conditions may also respond to nitroglycerin 2
• Oxygen is not recommended unless the patient is hypoxic 1

Late Presentation (>12 Hours After Symptom Onset)

Patients presenting >12 hours after chest pain onset who are hemodynamically stable and without ongoing symptoms should receive stabilization with protective drug therapy (aspirin, clopidogrel, beta-blockers, ACE inhibitors, high-dose statins) followed by noninvasive evaluation for inducible ischemia 1

• These patients do not require immediate reperfusion therapy 1
• Risk stratification with treadmill testing guides further management 1

Special Population Considerations

Women and Elderly Patients

• Women may present with atypical symptoms including nausea, fatigue, dyspnea, arm pain, jaw pain, or epigastric discomfort rather than classic chest pain 2, 3
• Elderly patients (≥75 years) may present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 2, 3
• Maintain high index of suspicion in these populations to avoid underdiagnosis 2, 3

Critical Pitfalls to Avoid

• Never delay transfer or treatment to obtain troponin levels when acute coronary syndrome is suspected and ECG shows STEMI 2, 3
• Do not assume young age excludes acute coronary syndrome - it can occur without traditional risk factors 2
• Do not rely on physical examination alone - it contributes minimally to diagnosing myocardial infarction unless shock is present 3
• Avoid using epinephrine or arterial vasoconstrictors in nitroglycerin-related hypotension - passive leg elevation and IV fluids are preferred 4

Cost-Effective Strategies

Medication Pricing Policies

• Government policies can significantly affect medication and device pricing - advocate for essential medications lists and price ceilings 1
• Streptokinase remains the most cost-effective thrombolytic agent for resource-limited settings 1
• Bare metal stents cost approximately $108 versus $444 for drug-eluting stents in countries with price controls 1

Selective Resource Utilization

• Troponin testing is optional if unavailable - ECG and clinical judgment guide initial management 1
• Reserve cardiac catheterization for high-risk patients post-thrombolysis rather than routine pharmaco-invasive approach 1
• Primary PCI without onsite surgical backup is acceptable in resource-limited settings 1

Systems of Care Development

• Establish hub-and-spoke STEMI care networks with contractual arrangements between facilities 1
• Enable ECG transmission via high-speed lines or cloud-based systems for remote interpretation 1
• Train first-contact providers in ECG interpretation and thrombolysis administration 1
• Focus on connecting as many patients as possible into formal STEMI care networks - this is likely the most impactful intervention for improving outcomes 1