Management of Chest Pain in Adults
Immediate Life-Saving Actions
Call 9-1-1 immediately for emergency transport rather than attempting office evaluation or self-transport, as EMS allows for intervention if complications occur en route and reduces mortality through earlier treatment. 1
First 10 Minutes - Critical Window
Obtain 12-lead ECG within 5-10 minutes of first patient contact to identify ST-segment elevation myocardial infarction (STEMI), ST-segment depression, T-wave inversions, or other ischemic changes 1, 2
Administer aspirin 160-325 mg (chewed, not swallowed) as soon as possible unless contraindicated by known aspirin allergy or active gastrointestinal bleeding 1, 2
Assess vital signs immediately including blood pressure, heart rate, respiratory rate, and oxygen saturation 2
Give sublingual nitroglycerin 0.3-0.6 mg if systolic blood pressure ≥90 mmHg and heart rate is 50-100 bpm 2, 3
Provide oxygen only if oxygen saturation <90% or respiratory distress is present 2
Risk Stratification Framework
High-Risk Features Requiring Immediate Hospital Transfer
- Prolonged ongoing rest pain >20 minutes with associated diaphoresis, dyspnea, nausea, or syncope 1, 4
- Hemodynamic instability (systolic BP <90 mmHg, heart rate <50 or >100 bpm) 4, 2
- Ongoing chest pain despite initial treatment 4
- ST-segment elevation or depression on ECG 1, 2
Intermediate-Risk Features
- Prior history of myocardial infarction or known coronary artery disease 1
- Age >70 years 1
- Diabetes mellitus or renal insufficiency 1
- Rest angina >20 minutes that has resolved 2
Diagnostic Evaluation Algorithm
In Primary Care/Pre-Hospital Setting
12-lead ECG is the ONLY investigation required for most patients in primary care while referral is made 1, 5
Do NOT delay transfer to ED for troponin testing in office settings when ACS is suspected 1, 2, 5
Serial ECGs should be obtained if initial ECG is nondiagnostic but clinical suspicion remains high 1, 6
In Emergency Department
Measure cardiac troponin as soon as possible to detect myocardial injury (sensitivity >90%, specificity >95%) 2
Serial troponin measurements at 0,3, and 6 hours if initial troponin is negative but suspicion remains 2
Continuous cardiac monitoring for arrhythmias 2
Risk stratification using TIMI or GRACE score to guide intensity of therapy 2
Immediate Medical Management
For All Suspected ACS Patients
Aspirin 160-325 mg (chewed) immediately unless contraindicated 1, 2
Morphine intravenously titrated to pain severity as the preferred analgesic, reducing sympathetic activation and myocardial oxygen demand 2
Sublingual nitroglycerin unless contraindicated (see above) 2, 3
Dual antiplatelet therapy with aspirin plus P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for confirmed ACS 2
Anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux 2
High-dose statin therapy 4
Beta-blockers (e.g., metoprolol) unless contraindicated by heart failure, bradycardia, or bronchospastic disease 4, 7
ACE inhibitors (e.g., lisinopril) for patients with systolic heart failure or post-MI 4, 8
Reperfusion Strategy - Time-Critical Decisions
STEMI Identified on ECG
Primary percutaneous coronary intervention (PCI) is PREFERRED with door-to-balloon time <90 minutes (acceptable <120 minutes) 1, 2
Fibrinolytic therapy with door-to-needle time <30 minutes if PCI unavailable 1, 4
- Pre-hospital thrombolysis reduces mortality by 17%, with 23 lives saved per 1000 per hour of earlier treatment 2
- Thrombolysis saves 35 lives per 1000 when given within first hour versus 16 lives per 1000 when given 7-12 hours after symptom onset 2
- In resource-limited settings, streptokinase is the most cost-effective thrombolytic agent 4
NSTEMI/Unstable Angina (Elevated Troponin Without ST-Elevation)
Admit to coronary care unit with continuous cardiac monitoring 1, 2
Initiate dual antiplatelet therapy, anticoagulation, and medical management as above 2
Timing of invasive coronary angiography determined by TIMI or GRACE risk score 2
Special Population Considerations
Women
May present with atypical symptoms: nausea, fatigue, shortness of breath, arm pain, jaw pain, epigastric discomfort rather than classic chest pain 1, 4, 2
Bilateral hand numbness with acute onset may represent anginal equivalent symptoms 2
Elderly Patients (≥75 Years)
May present with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1, 4, 2
Higher risk of persistent hypotension and renal dysfunction with treatment 8
Young Patients
- Do NOT assume young age excludes ACS - it can occur in adolescents without traditional risk factors 1, 2
Critical Pitfalls to Avoid
Do NOT use nitroglycerin response as a diagnostic tool - esophageal spasm and other conditions may also respond 1, 2
Do NOT delay transfer to ED for troponin testing in office settings when ACS is suspected 1, 2, 5
Sharp, pleuritic pain does NOT exclude ACS - pericarditis and atypical presentations can occur 2
Do NOT abruptly discontinue beta-blockers in patients with coronary artery disease - severe exacerbation of angina, MI, and ventricular arrhythmias have been reported 7
Physical examination contributes almost nothing to diagnosing MI unless shock is present 2
Total CK alone is neither sensitive nor specific enough to diagnose or exclude acute MI - must measure high-sensitivity cardiac troponin 2
Disposition Algorithm
STEMI on ECG
→ Immediate reperfusion: Primary PCI (door-to-balloon <90 min) OR fibrinolytic therapy (door-to-needle <30 min) 1, 4, 2
Elevated Troponin Without ST-Elevation
→ Admit to CCU with continuous monitoring + dual antiplatelet therapy + anticoagulation + medical management 1, 2
Normal ECG and Troponin but High Clinical Suspicion
→ Serial ECGs and troponins at 0,3,6 hours + observation unit admission 2, 6
Low-Risk Features with Normal Initial Workup
→ Consider provocative testing or coronary CT angiography for coronary artery disease evaluation (NOT for acute ACS diagnosis) 6