Chest pain medical therapy: Difference between revisions
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*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. | *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 a 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<ref name="pmid29942875">{{cite journal |vauthors=de Bliek EC |title=ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation |journal=Turk J Emerg Med |volume=18 |issue=1 |pages=1–10 |date=March 2018 |pmid=29942875 |pmc=6009807 |doi=10.1016/j.tjem.2018.01.008 |url=}}</ref><ref name="pmid27028120">{{cite journal |vauthors=Solhpour A, Chang KW, Arain SA, Balan P, Zhao Y, Loghin C, McCarthy JJ, Vernon Anderson H, Smalling RW |title=Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction |journal=Catheter Cardiovasc Interv |volume=88 |issue=5 |pages=709–715 |date=November 2016 |pmid=27028120 |doi=10.1002/ccd.26523 |url=}}</ref>. | ||
*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. | ||
Revision as of 19:34, 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[1][2].
- 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
- Special attention should be paid to airway, breathing, and circulation. Supplemental O2 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.
- ECG, cardiac marker, blood test and 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 diseases.
- Treat all underlying etiologies as clinically indicated.
Acute Pharmacotherapies
- For patients with coronary artery disease:
- Aspirin
- Nitroglycerin
- Morphine (if necessary)
- For patients with myocardial infarction:
- ↑ de Bliek EC (March 2018). "ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation". Turk J Emerg Med. 18 (1): 1–10. doi:10.1016/j.tjem.2018.01.008. PMC 6009807. PMID 29942875.
- ↑ Solhpour A, Chang KW, Arain SA, Balan P, Zhao Y, Loghin C, McCarthy JJ, Vernon Anderson H, Smalling RW (November 2016). "Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction". Catheter Cardiovasc Interv. 88 (5): 709–715. doi:10.1002/ccd.26523. PMID 27028120.