Chest pain treatment
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
In deciding on the most appropriate treatment strategy, first a correct diagnosis of the underlying cause of the chest pain should be obtained. 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. Surgery may be indicated in the setting of an MI (angioplasty) or in an aortic dissection.
Treatment
NICE guidelines for management of chest pain
General strategies for management of acute chest pain
- In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analysis are not sensitive enough (Chun & McGee 2004).
- The physician's typical approach is to rule-out the most dangerous causes of chest pain first (e.g., heart attack, blood clot in the lung, aneurysm). 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 thrombolytic agents is recommended after diagnosis
- Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient.
- If acute coronary syndrome (e.g.unstable angina) is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (CK-MB, troponin or myoglobin). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.
- 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
Immediate Management
- Special attention 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 lab tests are required to reach a diagnosis. Special attention to pain's nature and risk factors are required.
- ECG, cardiac marker, blood test and chest Xrays 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:
Surgery and Device Based Therapy
- For patients in which myocardial infarction is suspected, angioplasty may be indicated
- For patients with aortic dissections, emergent surgery may be required.[1][2][3][4][5]
- ↑ Chun AA, McGee SR (2004). "Bedside diagnosis of coronary artery disease: a systematic review". Am. J. Med. 117 (5): 334–43. doi:10.1016/j.amjmed.2004.03.021. PMID 15336583. Unknown parameter
|month=ignored (help) - ↑ Ringstrom E, Freedman J (2006). "Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines". Mt. Sinai J. Med. 73 (2): 499–505. PMID 16568192. Unknown parameter
|month=ignored (help) - ↑ Butler KH, Swencki SA (2006). "Chest pain: a clinical assessment". Radiol. Clin. North Am. 44 (2): 165–79, vii. doi:10.1016/j.rcl.2005.11.002. PMID 16500201. Unknown parameter
|month=ignored (help) - ↑ Haro LH, Decker WW, Boie ET, Wright RS (2006). "Initial approach to the patient who has chest pain". Cardiol Clin. 24 (1): 1–17, v. doi:10.1016/j.ccl.2005.09.007. PMID 16326253. Unknown parameter
|month=ignored (help) - ↑ Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.