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==Overview==
==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]].
A correct [[diagnosis]] of the underlying cause of the [[chest pain]] is necessrary 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 including  [[morphine]], [[oxygen]], [[nitrate]], [[aspirin]], [[ACE inhibitors]].


==Medical Therapy==
==Medical Therapy==
===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)''.
* 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 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 [[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.
* 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]]'''
*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 [[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


===Immediate Management===
===Immediate Management===
* Special attention should be paid to airway, breathing, and circulation. 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.
* 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===
*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]].
* For patients with [[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.
** [[Aspirin]]
*[[ECG]], [[Cardiac markers|cardiac marker,]] blood test and [[Chest x ray|chest x rays]] are initial primary tests done.
** [[Nitroglycerin]]
*[[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.]]
** [[Morphine]] (if necessary)
*Treat all underlying etiologies as clinically indicated<ref name="pmid29262011">{{cite journal |vauthors=Johnson K, Ghassemzadeh S |title= |journal= |volume= |issue= |pages= |date= |pmid=29262011 |doi= |url=}}</ref>;
* For patients with [[myocardial infarction]]:
** [[Heparin]]
** [[Beta-blockers]]
** [[ACE inhibitors]]
** [[Thrombolytic therapy]]
** [[Glycoprotein IIb/IIIa inhibitors]]
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.


OR
====Acute coronary syndrome====


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
*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.
*For patients with [[coronary artery disease]], recommended pharmacotherapy include; [[Aspirin]], [[Nitroglycerin]], [[Morphine]] (if necessary)
*For patients with [[myocardial infarction]] pharmacotherapy include Antiplatelete, [[beta-blockers]], [[ACE inhibitors]], [[statins]], [[anticoagulant]], [[Thrombolytic therapy]], [[Glycoprotein IIb/IIIa inhibitors]].
*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.


OR
====Pulmomary embolism====


The majority of cases of [disease name] are self-limited and require only supportive care.
*If a diagnosis of [[pulmonary embolism]] is suspected, [[Pulmonary angiography|a CT pulmonary angiogram (CTPA)]] should be performed for confirmation. A [[Ventilation/perfusion scan|VQ scan]] can also be used, however, this test is not as accurate.
*Hemodynamically stable patients should be placed on [[anticoagulants]] while hemodynamically unstable patients require immediate [[thrombolysis]].


OR
====Pneumothorax====


[Disease name] is a medical emergency and requires prompt treatment.
*[[Chest pain]] due to [[pneumothorax]] required immediate decompression with a [[chest tube]].


OR
====Cardiac tamponade====


The mainstay of treatment for [disease name] is [therapy].
*Suspected [[cardiac]] [[tamponade]] is diagnosed via bedside [[ultrasound]]. A pericardial window or needle [[pericardiotomy]] is therapeutic.


OR
====Aortic dissection====
 
*Aortic dissection is almost always a surgical emergency<ref name="pmid28833419">{{cite journal |vauthors=Zhao DL, Liu XD, Zhao CL, Zhou HT, Wang GK, Liang HW, Zhang JL |title=Multislice spiral CT angiography for evaluation of acute aortic syndrome |journal=Echocardiography |volume=34 |issue=10 |pages=1495–1499 |date=October 2017 |pmid=28833419 |doi=10.1111/echo.13663 |url=}}</ref>.
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
*The best test for diagnosis is CT angiography<ref name="pmid28336238">{{cite journal |vauthors=Shiber JR, Fontane E, Ra JH, Kerwin AJ |title=Hydropneumothorax Due to Esophageal Rupture |journal=J Emerg Med |volume=52 |issue=6 |pages=856–858 |date=June 2017 |pmid=28336238 |doi=10.1016/j.jemermed.2017.02.006 |url=}}</ref>.
*Aggressive controlling of [[hypertension]] is necessary and [[beta-blocker]] therapy is warranted to avert reflux tachycardia<ref name="pmid16492293">{{cite journal |vauthors=Khoynezhad A, Plestis KA |title=Managing emergency hypertension in aortic dissection and aortic aneurysm surgery |journal=J Card Surg |volume=21 Suppl 1 |issue= |pages=S3–7 |date=2006 |pmid=16492293 |doi=10.1111/j.1540-8191.2006.00213.x |url=}}</ref>.


OR
====Gastresophageal reflux disease====
 
*It is important to differentiate between acute coronary syndrome and GERD in a patient presenting with burning chest pain.
[Therapy] is recommended among all patients who develop [disease name].
*Proton pump inhibitors and H2 blockers are the first-line recommended treatments for GERD<ref name="pmid26469826">{{cite journal |vauthors=Alzubaidi M, Gabbard S |title=GERD: Diagnosing and treating the burn |journal=Cleve Clin J Med |volume=82 |issue=10 |pages=685–92 |date=October 2015 |pmid=26469826 |doi=10.3949/ccjm.82a.14138 |url=}}</ref>.
 
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==
==References==
{{Reflist|2}}
[[Category:Cardiology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Gastroenterology]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]

Latest revision as of 08:54, 6 March 2022

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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 is necessrary 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 including morphine, oxygen, nitrate, aspirin, ACE 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

Immediate Management

Acute coronary syndrome

Pulmomary embolism

Pneumothorax

Cardiac tamponade

Aortic dissection

  • Aortic dissection is almost always a surgical emergency[2].
  • The best test for diagnosis is CT angiography[3].
  • Aggressive controlling of hypertension is necessary and beta-blocker therapy is warranted to avert reflux tachycardia[4].

Gastresophageal reflux disease

  • It is important to differentiate between acute coronary syndrome and GERD in a patient presenting with burning chest pain.
  • Proton pump inhibitors and H2 blockers are the first-line recommended treatments for GERD[5].

References

  1. ↑ Johnson K, Ghassemzadeh S. PMID 29262011. Missing or empty |title= (help)
  2. ↑ Zhao DL, Liu XD, Zhao CL, Zhou HT, Wang GK, Liang HW, Zhang JL (October 2017). "Multislice spiral CT angiography for evaluation of acute aortic syndrome". Echocardiography. 34 (10): 1495–1499. doi:10.1111/echo.13663. PMID 28833419.
  3. ↑ Shiber JR, Fontane E, Ra JH, Kerwin AJ (June 2017). "Hydropneumothorax Due to Esophageal Rupture". J Emerg Med. 52 (6): 856–858. doi:10.1016/j.jemermed.2017.02.006. PMID 28336238.
  4. ↑ Khoynezhad A, Plestis KA (2006). "Managing emergency hypertension in aortic dissection and aortic aneurysm surgery". J Card Surg. 21 Suppl 1: S3–7. doi:10.1111/j.1540-8191.2006.00213.x. PMID 16492293.
  5. ↑ Alzubaidi M, Gabbard S (October 2015). "GERD: Diagnosing and treating the burn". Cleve Clin J Med. 82 (10): 685–92. doi:10.3949/ccjm.82a.14138. PMID 26469826.
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