Recurrent pain in acute coronary syndromes
During an acute coronary syndrome, recurrent pain that is refractory to medical treatment is a marker of an increased acute risk of mortality and recurrent cardiovascular events.
Treat reinfarction in patients with recurrent ST elevation with emergency reperfusion therapy (ie percutaneous coronary intervention or thrombolytic therapy); see Reperfusion therapy for STEMI.
Treat reinfarction in patients with non–ST elevation acute coronary syndrome with urgent coronary angiography, and prompt revascularisation if indicated; see Principles of management of NSTEACS.
Recurrent episodes of ischaemic chest pain may require intravenous glyceryl trinitrate infusion for symptom relief. This is usually only required for a short period; prolonged infusion rapidly induces tolerance. Use:
glyceryl trinitrate 10 micrograms/minute by intravenous infusion, increasing by 10 micrograms/minute every 3 minutes until pain is controlled, providing systolic blood pressure is 95 mmHg or more. glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate
Monitor patients for hypotension.
For continuing infrequent episodes of ischaemic pain, use:
1glyceryl trinitrate 5 mg transdermally, once daily, increasing if required up to 20 mg once daily. Apply for a maximum of 14 hours in a 24-hour period glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate
OR
1isosorbide mononitrate modified-release 30 mg orally, daily, increasing if required up to 120 mg daily. isosorbide mononitrate isosorbide mononitrate isosorbide mononitrate
For patients already taking a beta blocker, verapamil or diltiazem for angina, the dose of that drug should be maximised; see Treatment to prevent angina for detail of drugs and doses used to prevent angina.