Initial therapy for acute chest pain of possible cardiac origin

Chew, 2016 National Institute for Health and Clinical Excellence (NICE), 2010 [updated 2016]

For patients with acute chest pain of possible cardiac origin, the following therapy may be provided in the community or in an ambulance.

Give oxygen only if a patient is hypoxaemic (ie if oxygen saturation measured by pulse oximetry [SpO2] is less than 92%)Beasley, 2015Cabello, 2013. If the patient has acute hypoxaemia, reconsider the cause of the chest pain and/or consider the possibility of left ventricular failure.

For patients with suspected acute coronary ischaemia, or if coronary ischaemia cannot be ruled out, give aspirin for initial therapy, unless contraindicated. Use:

aspirin 300 mg orally, chewed or dissolved before swallowing. aspirin aspirin aspirin

For ongoing chest pain in haemodynamically stable patients, use:

1glyceryl trinitrate spray 400 to 800 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 sprays (1200 micrograms) if tolerated glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate

OR

1glyceryl trinitrate tablet 300 to 600 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses (1800 micrograms) if tolerated. glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate

For persisting chest pain, add an opioid; a suitable regimen is:

1fentanyl 25 to 50 micrograms intravenously, as an initial dose, repeated every 5 to 10 minutes if required to relieve pain fentanyl fentanyl fentanyl

OR

1morphine 2.5 to 5 mg intravenously, as an initial dose, repeated every 5 to 10 minutes if required to relieve pain. morphine morphine morphine

For older patients, start at the lower end of the dose range and consider other possible comorbidities that may add to adverse effects of opioids (eg hypotension)Parodi, 2016. Monitor for sedation (an indicator of opioid-induced ventilatory impairment) with a sedation score.