Chest pain treatment: Difference between revisions

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==Treatment==
===[[NICE guidelines for management of chest pain|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 [[ECG]]s, and determination of cardiac enzyme levels over time ([[creatine kinase|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]]:
** [[Heparin]]
** [[Beta-blockers]]
** [[ACE inhibitors]]
** [[Thrombolytic therapy]]
** [[Glycoprotein IIb/IIIa inhibitors]]
===Surgery and Device Based Therapy===
* For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated
* For patients with [[aortic dissection]]s, emergent surgery may be required.<ref name="pmid15336583">{{cite journal |author=Chun AA, McGee SR |title=Bedside diagnosis of coronary artery disease: a systematic review |journal=Am. J. Med. |volume=117 |issue=5|pages=334–43 |year=2004 |month=September |pmid=15336583 |doi=10.1016/j.amjmed.2004.03.021 |url=}}</ref><ref name="pmid16568192">{{cite journal |author=Ringstrom E, Freedman J |title=Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines |journal=Mt. Sinai J. Med. |volume=73 |issue=2|pages=499–505 |year=2006 |month=March |pmid=16568192 |doi= |url=http://www.mssm.edu/msjournal/73/732499.shtml}}</ref><ref name="pmid16500201">{{cite journal |author=Butler KH, Swencki SA |title=Chest pain: a clinical assessment |journal=Radiol. Clin. North Am. |volume=44 |issue=2 |pages=165–79, vii |year=2006 |month=March |pmid=16500201 |doi=10.1016/j.rcl.2005.11.002|url=}}</ref><ref name="pmid16326253">{{cite journal |author=Haro LH, Decker WW, Boie ET, Wright RS |title=Initial approach to the patient who has chest pain |journal=Cardiol Clin |volume=24 |issue=1 |pages=1–17, v |year=2006 |month=February |pmid=16326253|doi=10.1016/j.ccl.2005.09.007 |url=}}</ref><ref name="pmid17080889">{{cite journal |author=Fox M, Forgacs I |title=Unexplained (non-cardiac) chest pain |journal=Clin Med |volume=6 |issue=5 |pages=445–9 |year=2006 |pmid=17080889 |doi=|url=http://openurl.ingenta.com/content/nlm?genre=article&issn=1470-2118&volume=6&issue=5&spage=445&aulast=Fox}}</ref>

Revision as of 16:08, 22 January 2013

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

Surgery and Device Based Therapy

  1. ↑ 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)
  2. ↑ 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)
  3. ↑ 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)
  4. ↑ 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)
  5. ↑ Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain". Clin Med. 6 (5): 445–9. PMID 17080889.
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