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Chest Pain and ACS Triage

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In one line

·Chest pain triage means finding the life-threatening causes first: STEMI (complete blockage heart attack), NSTEMI (partial blockage heart attack), unstable angina (heart pain at rest or getting worse), aortic dissection (tear in the body's biggest artery), pulmonary embolism (a clot lodging in a lung artery) (blood clot in the lung), cardiac tamponade (the heart squeezed by fluid around it) (blood or fluid squeezing the heart so it cannot fill), tension pneumothorax (air trapped in the chest pushing the heart sideways), and esophageal rupture (hole torn in the swallowing tube).

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Normal physiology

·Your heart is a hollow muscle about the size of your fist. It sits in the center of your chest, tilted slightly to the left. The heart has four rooms—two upper rooms called atria that collect blood, and two lower rooms called ventricles that pump blood out. The left ventricle is the strongest because it has to push oxygen-rich blood all the way around your body. To do that powerful work, the heart muscle itself needs fuel.

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What goes wrong

·Chest pain triage is hunting for the handful of upstream breaks that will kill someone in minutes to hours if you miss them. Usually the problem is supply versus demand: either the coronary arteries cannot deliver enough oxygen-rich blood, or the heart is being forced to work so hard that even open arteries cannot keep up.

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Hallmark signs

·Pressure, squeezing, or heaviness in the center of the chest (often brought on by activity, relieved by rest)
·Pain or discomfort spreading to the left arm, jaw, neck, back, or stomach
·Sweating (cold, clammy skin) without obvious reason
·Shortness of breath (with or without chest discomfort)
·Nausea or vomiting
·Light-headedness or feeling faint
·Sudden, severe 'ripping' or 'tearing' pain radiating to the back
·Sharp, stabbing chest pain that worsens with deep breathing or lying flat, plus a scratchy sound on exam

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Red flags · escalate now

·Chest pain with sweating, shortness of breath, or feeling faint—these suggest the heart is in serious trouble right now.
·New irregular heartbeat or very slow or very fast pulse—the heart's electrical system may be failing.
·Blood pressure dropping or signs of shock (cool, clammy skin; confusion; weak pulse)—the heart is not pumping enough blood to keep the body alive.
·Sudden tearing pain to the back—the aorta may be ripping open, a true surgical emergency.
·Active bleeding or very high bleeding risk in someone who needs blood thinners—treatment must be carefully balanced to save the heart without causing dangerous bleeding.

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Workup

·12-lead electrocardiogram (EKG or ECG)
·High-sensitivity cardiac troponin I or T
·Chest X-ray (two views: front and side)
·CT pulmonary angiography (CTPA)
·CT angiography of the chest (with IV contrast)
·D-dimer (blood test)
·Complete blood count (CBC) and basic metabolic panel (BMP)
·Brain natriuretic peptide (BNP or NT-proBNP)

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Treatment

·12-lead EKG within 10 minutes of arrival
·For ST-elevation MI (STEMI): Activate the cath lab for percutaneous coronary intervention (PCI) within 90 minutes, or give fibrinolytic therapy (e.g. tenecteplase, alteplase) within 30 minutes if PCI is not available. Give aspirin 162–325 mg chewed, a P2Y12 inhibitor (clopidogrel 600 mg, ticagrelor 180 mg, or prasugrel 60 mg), and anticoagulation (unfractionated heparin bolus 60 units/kg then 12 units/kg/hr, or enoxaparin 1 mg/kg subcutaneous every 12 hours)
·High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg) started immediately and continued daily
·For aortic dissection: IV beta-blocker (esmolol 500 mcg/kg bolus then 50–200 mcg/kg/min, or labetalol 20 mg IV push then 40–80 mg every 10 minutes) to slow heart rate to 60 bpm, THEN vasodilator (nicardipine 5 mg/hr IV or nitroprusside 0.3 mcg/kg/min IV) to lower systolic blood pressure to 100–120 mmHg. Emergent cardiothoracic surgery consult for Type A; medical management ± endovascular repair for Type B
·For pulmonary embolism (a clot lodging in a lung artery): Anticoagulation with unfractionated heparin (80 units/kg bolus, then 18 units/kg/hr IV), low-molecular-weight heparin (enoxaparin 1 mg/kg subcutaneous every 12 hours), or a direct oral anticoagulant (apixaban 10 mg twice daily × 7 days, then 5 mg twice daily; rivaroxaban 15 mg twice daily × 21 days, then 20 mg daily). If massive PE with shock or severe right heart strain, give systemic fibrinolysis (alteplase 100 mg IV over 2 hours) or catheter-directed therapy
·For tension pneumothorax: Immediate needle decompression (14- or 16-gauge angiocatheter inserted at the 2nd intercostal space, midclavicular line, or 4th–5th intercostal space, anterior axillary line) followed by chest tube (28–32 French) placement
·Supplemental oxygen to keep oxygen saturation ≥ 90% (but avoid hyperoxia > 96% in confirmed MI, per recent data suggesting possible harm)

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NCLEX trap

·First rule out aortic dissection (a tear in the body's biggest artery), tension pneumothorax (collapsed lung with air pressing on the heart), and pulmonary embolism (a clot lodging in a lung artery) (clot in the lung). Giving blood thinner to a patient with a torn aorta causes deadly bleeding. Always get an EKG (heart tracing) and detailed history before starting blood thinners.
·A normal EKG does NOT rule out NSTEMI (a heart attack without the big ST-wave change) or unstable angina (dangerous narrowing that could become a full heart attack soon). You must check troponin (a blood test that shows dead heart muscle) and repeat the EKG in 10 minutes, then again at 3 hours if the first troponin is normal.
·Sharp pain that hurts more when you breathe in could be pericarditis (swelling of the sac around the heart), pneumonia, or pleurisy (swelling of the lung lining). But some heart attacks — especially those on the bottom wall of the heart — can also cause pain that changes with breathing. Always get an EKG and troponin to be sure.
·Young adults can have heart attacks if they use cocaine (which makes arteries clamp shut), have family history of early heart disease, smoke heavily, or have conditions like diabetes or very high cholesterol. Age alone never rules out a heart attack. Always check EKG and troponin.
·Aortic dissection (the main artery is tearing open) can happen with normal, high, or even low blood pressure. Sudden ripping or tearing pain between the shoulder blades is aortic dissection until proven otherwise. Order an emergency CT scan of the chest with IV contrast right away. Do NOT give blood thinners until dissection is ruled out.
·Some heart attack patients feel better after antacids by chance or because their anxiety drops when they think the problem is minor. Symptom relief after antacids does NOT rule out heart attack. You must still get an EKG, troponin, and full history. Never let temporary relief fool you into skipping the work-up.

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