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===General Strategies for the Management of Acute Chest Pain===
===General Strategies for the Management of Acute Chest Pain===


*Obtaining a thorough [[patient history]] is often the most valuable toll in coming to a diagnosis. In [[angina pectoris]], for example, blood tests and other analysis are not sufficient to make a diagnosis ''(Chun & McGee 2004)''.
*Obtaining a thorough [[patient history]] is often the most valuable tool in coming to a diagnosis. In [[angina pectoris]], for example, blood tests and other analyses are not sufficient to make a diagnosis ''(Chun & McGee 2004)''.
*The physician's typical approach is to rule-out the most dangerous causes of [[chest pain]] first (e.g., [[myocardial infarction]], [[pulmonary embolism]]). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Emergency [[reperfusion therapy]] either by [[percutaneous coronary intervention]] or [[Thrombolytics|thrombolytic agents]] is recommended after diagnosis.
*The physician's typical approach is to rule out the most dangerous causes of [[chest pain]] first (e.g., [[myocardial infarction]], [[pulmonary embolism]]). By sequential elimination or confirmation from the most serious to the least serious cases, a diagnosis of the origin of the pain is eventually made. Emergency [[reperfusion therapy]] either by [[percutaneous coronary intervention]] or [[Thrombolytics|thrombolytic agents]] is recommended after diagnosis.
*Often, no definite cause will be found, and the focus in these cases is on excluding severe conditions and reassuring the patient.
*Often, no definite cause will be found, and the focus in these cases is on excluding severe conditions and reassuring the patient.
*If [[acute coronary syndrome]] (e.g. [[unstable angina]]) is suspected, many patients are admitted briefly for observation, sequential [[ECG]]s, and serial [[enzymes]] ([[creatine kinase|CK-MB]], [[troponin]] or [[myoglobin]]). On occasion, later out-patient testing may be necessary to follow-up and make better determination on the specific cause and the appropriate therapy.
*If [[acute coronary syndrome]] (e.g. [[unstable angina]]) is suspected, many patients are admitted briefly for observation, sequential [[ECG]]s, and serial [[enzymes]] ([[creatine kinase|CK-MB]], [[troponin]] or [[myoglobin]]). On occasion, later out-patient testing may be necessary to follow-up and make a better determination on the specific cause and the appropriate therapy.
*Recommendations regarding the minimum length of stay in a monitored bed for a patient who has no further symptoms have decreased in recent years to 12 h or less.
*Recommendations regarding the minimum length of stay in a monitored bed for a patient who has no further symptoms have decreased in recent years to 12 h or less.


'''To read about NICE guidelines for management of chest pain, click [[NICE guidelines for management of chest pain|here]]'''
'''To read about NICE guidelines for the management of chest pain, click [[NICE guidelines for the management of chest pain|here]]'''


===Immediate Management===
===Immediate Management===


*Special attention should be paid to [[airway]], [[breathing]], and [[circulation]]. [[Oxygen|Supplemental O<sub>2</sub>]] should be administered to patients with suspected [[coronary artery disease]].
*Special attention should be paid to [[airway]], [[breathing]], and [[circulation]]. [[Oxygen|Supplemental O<sub>2</sub>]] should be administered to patients with suspected [[coronary artery disease]].
*Once it's ensured that the patient has stable vitals, then a detailed history, [[physical examination]] and laboratory tests are required to obtain a diagnosis. Special attention should be paid to risk factors and the nature of the patient's pain.
*Once it's ensured that the patient has stable vitals, then a detailed history, [[physical examination]], and laboratory tests are required to obtain a diagnosis. Special attention should be paid to risk factors and the nature of the patient's pain.
*[[ECG]], [[Cardiac markers|cardiac marker,]] blood test and [[Chest x ray|chest x rays]] are initial primary tests done.
*[[ECG]], [[Cardiac markers|cardiac marker,]] blood test and [[Chest x ray|chest x rays]] are initial primary tests done.
*[[Nitroglycerine]] and [[proton pump inhibitors]] are usually the initial [[treatment]] given. However, caution should be taken by the physician in diagnosis based on response to theses therapies as relief of pain on antacids doesn't exclude [[Ischemic heart disease|ischemic heart diseases.]]
*[[Nitroglycerine]] and [[proton pump inhibitors]] are usually the initial [[treatment]] given. However, caution should be taken by the physician in diagnosis based on response to theses therapies as relief of pain on antacids doesn't exclude [[Ischemic heart disease|ischemic heart diseases.]]
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**[[Thrombolytic therapy]]
**[[Thrombolytic therapy]]
**[[Glycoprotein IIb/IIIa inhibitors]]
**[[Glycoprotein IIb/IIIa inhibitors]]
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Disease Name===
*'''1 Stage 1 - Name of stage'''
**1.1 '''Specific Organ system involved 1'''
***1.1.1 '''Adult'''
****Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)'''
****Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
****Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
****Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
****Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
****Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
***1.1.2 '''Pediatric'''
****1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
*****Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
*****Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
*****Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
*****Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
*****Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
*****Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
*****Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
*****Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
*****Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
**1.2 '''Specific Organ system involved 2'''
***1.2.1 '''Adult'''
****Preferred regimen (1): [[drug name]] 500 mg PO q8h
***1.2.2  '''Pediatric'''
****Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
*2 '''Stage 2 - Name of stage'''
**2.1 '''Specific Organ system involved 1 '''
**:'''Note (1):'''
**:'''Note (2)''':
**:'''Note (3):'''
***2.1.1 '''Adult'''
****Parenteral regimen
*****Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
*****Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
*****Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
****Oral regimen
*****Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
*****Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
*****Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
*****Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
*****Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
*****Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
***2.1.2 '''Pediatric'''
****Parenteral regimen
*****Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
*****Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
*****Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
****Oral regimen
*****Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
*****Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
*****Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
*****Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
*****Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
*****Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
**2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**:'''Note (1):'''
**:'''Note (2)''':
**:'''Note (3):'''
***2.2.1 '''Adult'''
****Parenteral regimen
*****Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
*****Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
*****Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
****Oral regimen
*****Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
*****Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
*****Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
*****Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
*****Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
*****Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
***2.2.2 '''Pediatric'''
****Parenteral regimen
*****Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
*****Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
*****Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
****Oral regimen
*****Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
*****Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
*****Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
*****Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
*****Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
*****Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
==References==
{{Reflist|2}}
[[Category:Cardiology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Gastroenterology]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]

Revision as of 19:31, 27 August 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

A correct diagnosis of the underlying cause of the chest pain should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If myocardial infarction or ischemia is suspected, the immediate pharmacotherapies often used include morphine, oxygen, nitrate, aspirin, and possibly also beta-blockers, ACE inhibitors, thrombolytic therapy and glycoprotein IIb/IIIa inhibitors.

Medical Therapy

General Strategies for the Management of Acute Chest Pain

  • Obtaining a thorough patient history is often the most valuable tool in coming to a diagnosis. In angina pectoris, for example, blood tests and other analyses are not sufficient to make a diagnosis (Chun & McGee 2004).
  • The physician's typical approach is to rule out the most dangerous causes of chest pain first (e.g., myocardial infarction, pulmonary embolism). By sequential elimination or confirmation from the most serious to the least serious cases, a diagnosis of the origin of the pain is eventually made. Emergency reperfusion therapy either by percutaneous coronary intervention or thrombolytic agents is recommended after diagnosis.
  • Often, no definite cause will be found, and the focus in these cases is on excluding severe conditions and reassuring the patient.
  • If acute coronary syndrome (e.g. unstable angina) is suspected, many patients are admitted briefly for observation, sequential ECGs, and serial enzymes (CK-MB, troponin or myoglobin). On occasion, later out-patient testing may be necessary to follow-up and make a better determination on the specific cause and the appropriate therapy.
  • Recommendations regarding the minimum length of stay in a monitored bed for a patient who has no further symptoms have decreased in recent years to 12 h or less.

To read about NICE guidelines for the management of chest pain, click here

Immediate Management

Acute Pharmacotherapies

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