What is the appropriate management for a patient with chest pain?

Management of Acute Chest Pain

Obtain a 12-lead ECG within 10 minutes of patient arrival and immediately administer aspirin 160-325 mg (chewed) while simultaneously assessing for life-threatening conditions including acute coronary syndrome, aortic dissection, and pulmonary embolism. 1, 2

Immediate Actions (First 5-10 Minutes)

Time-Critical Assessment:

• Record and interpret 12-lead ECG within 5-10 minutes of first patient contact 3, 1, 2
• Assess vital signs including heart rate, blood pressure, oxygen saturation, and signs of hemodynamic instability (HR <40 or >100/min, SBP <100 or >200 mmHg, cold extremities) 2
• Draw blood samples immediately for high-sensitivity cardiac troponin (hs-cTn) and CK-MB mass on arrival 3, 1, 2

Immediate Medical Interventions:

• Administer aspirin 160-325 mg orally (chewed, not swallowed) unless contraindicated by known allergy or active GI bleeding 3, 1, 2
• Provide intravenous morphine 4-8 mg (with additional 2 mg doses every 5 minutes as needed) for pain relief, as pain increases sympathetic activation and myocardial oxygen demand 3, 2
• Give sublingual nitroglycerin unless systolic BP <90 mmHg or heart rate <50 or >100 bpm 3, 2, 4
• Administer oxygen 2-4 L/min if patient is breathless, has heart failure features, or oxygen saturation is low 2

Risk Stratification Based on ECG Findings

STEMI (ST-Elevation ≥1 mV in contiguous leads):

• Initiate immediate reperfusion therapy with door-to-needle time for thrombolysis <30 minutes OR first medical contact to balloon time <90 minutes (preferred) 3, 1, 2
• Transfer directly to cardiac catheterization laboratory if PCI facilities available 2
• Pre-hospital thrombolysis reduces mortality by 17%, saving 35 lives per 1000 when given within first hour versus 16 lives per 1000 when given 7-12 hours after symptom onset 1

NSTEMI/Unstable Angina (ST-depression, T-wave inversions, or normal ECG with positive troponin):

• Admit to coronary care unit with continuous cardiac monitoring 3, 1, 2
• Initiate dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) 1
• Start anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux 1
• Low-molecular-weight heparin can be started in the emergency department 3

Normal ECG with Ongoing Symptoms:

• Repeat serial ECGs if clinical suspicion remains high 1
• Obtain second troponin measurement at 10-12 hours after symptom onset 3, 1, 2
• Consider bedside two-dimensional echocardiography to detect regional wall motion abnormalities and exclude aortic dissection, pericardial effusion, or pulmonary embolism 2

High-Risk Features Requiring CCU Admission

Identify patients with any of the following: 3, 1, 2

• Severe continuing pain or prolonged ongoing rest pain
• Ischemic ECG changes (ST-segment elevation or depression)
• Positive troponin test (>99th percentile)
• Left ventricular failure or hemodynamic instability
• Recurrent ischemia or major arrhythmias
• Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or new murmurs

Life-Threatening Differential Diagnoses

Acute Coronary Syndrome:

• Retrosternal chest discomfort building gradually over minutes, with radiation to left arm/neck/jaw, associated with dyspnea, nausea, diaphoresis, or lightheadedness 1

Acute Aortic Syndromes:

• Sudden-onset tearing or ripping pain with radiation to the back 1
• Perform transthoracic/transesophageal echocardiography, CT, or MR imaging if suspected 2

Pulmonary Embolism:

• Sudden dyspnea and pleuritic chest pain, particularly with risk factors 1
• Consider pulmonary scintigraphy or spiral CT examination 2

Other Critical Conditions:

• Acute pericarditis, pneumothorax, and pneumonia are rare compared to acute coronary syndromes but remain life-threatening 3

Low-Risk Patient Management

Chest Pain Unit Observation (for patients with normal ECG, negative initial troponin, no high-risk features): 3, 2, 5

• Observe for 10-12 hours after symptom onset in chest pain unit
• Equip unit with resuscitation capabilities, cardiac rhythm monitoring with arrhythmia alarm, and continuous ST-segment monitoring 3
• Repeat troponin at 10-12 hours after symptom onset 3, 2
• Proceed to stress testing before discharge if serial biomarkers remain negative 2
• This approach is safe, effective, and cost-saving compared to routine hospitalization 3, 5, 6

Critical Pitfalls to Avoid

• Do not rely on nitroglycerin response as diagnostic for ACS, as esophageal spasm and other conditions may also respond 1, 4
• Do not delay transfer to ED for troponin testing in office settings when ACS is suspected 1
• Do not assume young age excludes ACS, as it can occur in adolescents without risk factors 1
• Do not dismiss sharp, pleuritic pain as excluding ACS, since pericarditis and atypical presentations occur 1
• Physical examination contributes almost nothing to diagnosing myocardial infarction unless shock is present 1
• Do not use total CK alone as it is neither sensitive nor specific enough to diagnose or exclude acute myocardial infarction 1

Special Population Considerations

Women:

• Emphasize accompanying symptoms like nausea, fatigue, dyspnea, arm pain, jaw pain, and epigastric discomfort, as women often present with atypical symptoms and are at risk for underdiagnosis 1

Older Adults (≥75 years):

• Consider ACS in patients presenting with isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1

Transport and Pre-Hospital Care

• Call ambulance immediately for suspected ACS rather than attempting office-based evaluation, as transport by EMS allows for intervention if complications occur en route 1
• Pre-hospital ECG use reduces in-hospital delay time and mortality among patients with acute chest pain 1
• Trained personnel can administer aspirin, provide defibrillation, and manage complications during transport 1