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Angina Pectoris in Emergency Medicine Treatment & Management

  • Author: Marc D Haber, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Feb 18, 2015
 

Prehospital Care

Often, patients with angina pectoris rest or lie down to alleviate the pain. If the patient is not naive to cardiac disease, he or she may have access to nitroglycerin. Often, the patient uses nitroglycerin at home to palliate his or her symptoms. A patient who has known stable angina often is able to report what exacerbates the condition and what (as well as how often) is a "normal" number of tablets for him or her to use prior to alleviation of anginal symptoms. Patients are often instructed by their physicians that the use of more than 3 tablets of nitroglycerin necessitates a higher level of care (eg, calling for an ambulance). Some patients are instructed to take aspirin as well. A knowledgeable patient who reports a change in the pattern or presentation of his or her symptoms should be suspected as having worsening or unstable angina. However, any patient who presents to the ED with symptoms of angina should be assessed promptly for signs of acute myocardial infarction (AMI).

Most prehospital care for angina pectoris consists of administering nitroglycerin, oxygen, and aspirin. The ability to obtain a prehospital ECG is becoming more prevalent.

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Emergency Department Care

In the ED, the patient who complains of chest discomfort needs to be immediately assessed for AMI as well as other high-risk diagnoses (eg, aortic dissection, pulmonary embolism). Vital in this assessment is an early ECG and a rapid history and physical examination. Should this initial encounter not reveal a definitive diagnosis, then a more focused history and physical examination needs to be performed. Serial ECGs, especially in the setting of changing symptoms, is imperative. Labeling the ECGs with the patient's level of pain is often useful. A consecutive series of ECGs taken when a patient is having "10/10" pain, "3/10" pain, and "0/10" pain may yield valuable information that would not be readily apparent with an isolated cardiogram. Continuous telemetry monitoring is recommended for higher-risk patients.[21]

The patient who presents with chest pain is presumed to have underlying clinically significant cardiac pathology (ie, unstable angina or NSTEMI).

The initial treatment consists of administration of oxygen, aspirin, nitroglycerin, morphine, and a beta-blocker. Given an altered, yet nondiagnostic ECG and no contraindications, further treatment with heparin (low-molecular weight or unfractionated), clopidogrel, or other antiplatelet agents may be initiated. Most often, an additional abnormal marker (eg, an elevated serum troponin, myoglobin, or CPK level) will be verified prior to antiplatelet therapy.

For persistent symptoms unresponsive to initial therapy, glycoprotein inhibitors can be considered. These appear to demonstrate an additional benefit in the patient population who will be undergoing cardiac catheterization (PCI).[22] Persistent pain, in spite of this treatment, suggests either AMI or an alternative diagnosis. In the case of AMI, angioplasty or thrombolytics should be administered if available and not contraindicated. The American College of Cardiology offers an excellent evidenced-based online treatment resource (see American College of Cardiology Clinical Statements/Guidelines).

Atypical presentations of angina, unfortunately, are often diagnosed retrospectively. This subset of patients is identified either when their condition progresses to STEMI or through elevated serum marker levels or cardiac dysrhythmia (often ventricular tachycardia or fibrillation). It cannot be understated that the variance of expression of angina pectoris makes it imperative that the clinician have a high level of suspicion for the disease. Little value exists in relying on a constancy of expression or on ECG, history, or physical examination alone for making the diagnosis. Angina pectoris should be considered as well as an extensive differential diagnosis, in just about any patient who presents to the ED with chest pain with or without other nonspecific complaints.

Syndrome X and Prinzmetal angina are not diagnosed in the ED, but the patient's medical records or primary care physician may be helpful in recognizing these disorders.

Consultation

In the setting of unstable angina or AMI, consultation with a cardiologist is warranted.

Hospitalization

Admission is indicated for patients with unstable angina. Patients with angina pectoris who are admitted for alternative reasons do not routinely require telemetry monitoring.

Low-risk, pain-free patients who are admitted with nondiagnostic ECGs and negative cardiac marker results, often do not require telemetry monitoring as inpatients.

Patients admitted with UA/NSTEMI will likely undergo percutaneous transluminal coronary angioplasty (PTCA) if clinically indicated. If catheterization is not available, hospital transfer is suggested.

Transfer

Transfer of the high-risk patient to an active catheterization center is recommended. This may be done from the inpatient setting after the patient has been stabilized in the ED.

Follow-up

Any discharged patient with suspected angina should have close primary or cardiology follow-up care.

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Contributor Information and Disclosures
Author

Marc D Haber, MD Assistant Professor, Department of Emergency Medicine, Tufts University School of Medicine; Clinical Associate of Radiology, Baystate Medical Center; Past President of Young Physician Section, AAEM

Marc D Haber, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Radiology, Radiological Society of North America, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas A Brunell, MD, MA, FACEP, FAAEM Director, Emergency Medicine Education, St Francis Hospital and Medical Center; Assistant Professor of Traumatology and Emergency Medicine, University of Connecticut Medical Center

Thomas A Brunell, MD, MA, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. Clarendon E. The Life of Edward, Earl of Clarendon. Oxford at the Clarendon Press; 1827. 18.

  2. Jay V. The legacy of William Heberden. Arch Pathol Lab Med. 2000 Dec. 124(12):1750-1. [Medline].

  3. Kelemen MD. Angina pectoris: evaluation in the office. Med Clin North Am. 2006 May. 90(3):391-416. [Medline].

  4. Maseri A, Crea F, Kaski JC, Davies G. Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis. 1992 Jul-Aug. 35(1):1-18. [Medline].

  5. Servoss SJ, Januzzi JL, Muller JE. Triggers of acute coronary syndromes. Prog Cardiovasc Dis. 2002 Mar-Apr. 44(5):369-80. [Medline].

  6. Yang EH, Lerman A. Management of the patient with chest pain and a normal coronary angiogram. Cardiol Clin. 2005 Nov. 23(4):559-68, viii. [Medline].

  7. Mozaffarian D, Benjamin EJ, Go AS, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2015 update: a report from the american heart association. Circulation. 2015 Jan 27. 131(4):e29-e322. [Medline].

  8. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009 Jan 27. 119(3):e21-181. [Medline]. [Full Text].

  9. Centers for Disease Control and Prevention. Prevalence of heart disease--United States, 2005. MMWR Morb Mortal Wkly Rep. 2007 Feb 16. 56(6):113-8. [Medline]. [Full Text].

  10. Almeda FQ, Kason TT, Nathan S, Kavinsky CJ. Silent myocardial ischemia: concepts and controversies. Am J Med. 2004 Jan 15. 116(2):112-8. [Medline].

  11. Clarke WB, Austin SM, Shah PM, Griffin PM, Dove JT, McCullough J, et al. Spectral energy of the first heart sound in acute myocardial ischemia. A correlation with electrocardiographic, hemodynamic, and wall motion abnormalities. Circulation. 1978 Mar. 57(3):593-8. [Medline].

  12. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. 2002 Mar. 9(3):203-8. [Medline].

  13. Tierney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med. 1985 Jul. 13(7):526-31. [Medline].

  14. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989 Nov 15. 64(18):1087-92. [Medline].

  15. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996 Jul. 14(4):341-5. [Medline].

  16. Rogers JT. Risk Management in Emergency Medicine. 1985. 4-6.

  17. Bamberg F, Truong QA, Blankstein R, Nasir K, Lee H, Rogers IS, et al. Usefulness of age and gender in the early triage of patients with acute chest pain having cardiac computed tomographic angiography. Am J Cardiol. 2009 Nov 1. 104(9):1165-70. [Medline]. [Full Text].

  18. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002 Dec 4. 288(21):2693-700. [Medline].

  19. Miller CD, Hwang W, Hoekstra JW, Case D, Lefebvre C, Blumstein H, et al. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med. 2010 Sep. 56(3):209-219.e2. [Medline].

  20. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26. 367(4):299-308. [Medline].

  21. Chen EH, Mills AM. Is it necessary to admit low-risk patients with suspected acute coronary syndrome to inpatient telemetry beds?. Ann Emerg Med. 2005 Nov. 46(5):440-4. [Medline].

  22. Kou V, Nassisi D. Unstable angina and non-ST-segment myocardial infarction: an evidence-based approach to management. Mt Sinai J Med. 2006 Jan. 73(1):449-68. [Medline].

  23. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation. 1994 Apr. 89(4):1545-56. [Medline].

  24. Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet. 2004 Sep 4-10. 364(9437):849-57. [Medline].

  25. American Heart Association, American Stroke Association. Heart Disease and Stroke Statistics --2006 Update. Available at http://circ.ahajournals.org/content/113/6/e85.extract.

  26. [Guideline] Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4. 44(3):671-719. [Medline].

  27. [Guideline] Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002 Oct 2. 40(7):1366-74. [Medline]. [Full Text].

  28. Kaski JC, Rosano GM, Collins P, Nihoyannopoulos P, Maseri A, Poole-Wilson PA. Cardiac syndrome X: clinical characteristics and left ventricular function. Long-term follow-up study. J Am Coll Cardiol. 1995 Mar 15. 25(4):807-14. [Medline].

 
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