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Chest Pain, Treatment and Managment - Coggle Diagram
Chest Pain
Epidemiology
2nd most common reason adults present to the ER in the U.S.
Lifetime prevalence: about at 20% to 40% in the US population, and the symptom is reported more often by women than men.
The cause for >6.5 million ED visits & nearly 4 million outpatient visits annually
Only 5.1% of all ED chest pain patients have an acute coronary syndrome (ACS), and more than half are ultimately found to have a noncardiac cause
Chest pain is ~1% of primary care visits: 2%–4% have unstable angina or MI; musculoskeletal (~33%), GI (10–20%), and cardiac (12–14%) causes
Risk Factors
Cardiac
Factors that increase CAD/CVD
Older age
Male sex
Diabetes mellitus
HTN
Hyperlipidemia
Smoking
Obesity
FH of premature CAD
Established vascular disease
Past MI, PCI or CABG
Past CVA/TIA
PAD
CKD
CHF
Non-Cardiac
GERD
Esophageal disorders
MSK/chest wall conditions
PE
Aortic disorders
Psychological disorders
Integration of Infrmation Technologies
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Electronic Health Records (EHR): Document chest pain symptoms, risk factors, diagnostic findings, treatment plans, and follow up.
Clinical Decision Support: Utilize HEART score, ASCVD risk calculator, and evidence based guidelines to guide risk assessment and management.
Telehealth: Follow up on symptoms, medication adherence, and lifestyle modifications in appropriately stable patients.
Remote Monitoring: Track blood pressure, heart rate, and symptoms using home monitoring devices.
Patient Portals: Provide test results, medication instructions, educational resources, and communication with providers.
Patient Education Tools: Utilize digital resources to educate patients on cardiovascular risk reduction and emergency warning signs.
Assessment
Medical history: CAD, hypertension, hyperlipidemia, diabetes, GERD, prior MI.
Risk factors: Smoking, obesity, family history of premature CAD, sedentary lifestyle.
Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, dizziness, palpitations, syncope.
Physical examination: Vital signs, oxygen saturation, heart and lung sounds, peripheral pulses, edema, chest wall tenderness, signs of poor perfusion
HPI: OLDCHART: asking the onset, location, duration, character, radiation, severity, associated symptoms, aggravating and relieving factors
Follow up
Emergency evaluation for new, worsening, or persistent chest pain
Timely outpatient follow up based on risk and clinical findings.
Cardiology referral for suspected CAD or abnormal cardiac testing.
Monitor symptoms, medication adherence, and cardiovascular risk factors.
Evaluation of Outcomes:
Reduced chest pain frequency, severity, and duration.
Improved exercise tolerance and daily functioning.
Improved blood pressure, cholesterol, and glucose control.
Patient understands treatment plan, lifestyle changes, and emergency warning signs.
History
HPI: Onset, Provocation, Associated Sx, Pain Quality, Region/Radiation, Severity, Time
Marriott’s Cardinal Questions
Is the pain deep inside or feel as though it’s close to the surface?
Can you point to the area of pain with one finger ?
Does the pain have maximal intensity from its onset, or is there a build-up for several seconds?
Pharmacotherapeutics and Treatment Planning
Pharmacotherapeutics & Treament
ACS: Aspirin, P2Y12 inhibitors, anticoagulants, nitrates, and high intensity statins as indicated.
Stable angina: Beta blockers or calcium channel blockers; nitroglycerin for acute symptom relief.
GERD: Proton pump inhibitors (omeprazole) or H2 blockers (famotidine).
Musculoskeletal pain: Acetaminophen or NSAIDs when appropriate.
Pericarditis: NSAIDs and colchicine when indicated.
Nonpharmacologic Managment
Smoking cessation, heart healthy diet, regular physical activity when medically cleared.
Weight management and control of hypertension, diabetes, and hyperlipidemia.
Stress reduction and avoidance of identified chest pain triggers.
Patient education on medication adherence and emergency warning signs.
Safety Considerations and Monitoring
Nitrates: Avoid with PDE5 inhibitors or significant hypotension; monitor blood pressure and dizziness.
Aspirin, antiplatelets, and anticoagulants: Monitor for bleeding and contraindications.
Beta blockers: Monitor heart rate, blood pressure, fatigue, and bradycardia.
NSAIDs: Use cautiously with renal disease, GI bleeding risk, or cardiovascular disease.
Monitor treatment response, adverse effects, adherence, and patient specific risk factors.
Diagnostics & Screening
Risk stratification, EKG, troponin, lipid panel, lp(a), ApoB, high sensitive CRP, D-dimer, CMP, CBC, coagulation studies, echo, stress test, CXR, EGD, US AAA, GAD7, A1C
Treatment and Managment
Suspected ACS or other life threatening condition: Immediate emergency department evaluation and EMS transport.
Suspected ACS: Aspirin when indicated and no contraindications; additional medications and interventions according to emergency protocols.
Stable angina: Guideline directed medical therapy, risk factor modification, and cardiology referral as appropriate.
Oxygen only for hypoxemia or another clinical indication.
GERD: Lifestyle modifications and acid suppression when indicated.
Musculoskeletal pain: Appropriate analgesics, activity modification, and supportive care after serious causes are excluded.
Address cardiovascular risk factors, including blood pressure, cholesterol, diabetes, smoking, and physical activity.