Cardiac Chest Pain
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals involved in the assessment and management of residential aged care patients with chest pain due to stable angina and acute coronary syndromes (ACS). It addresses issues that may occur in RACF, particularly:
Assessment of residents with chest pain; Initial management of angina and acute coronary syndromes; asic life support for cardiac arrest.
This CIS covers:
About cardiac chest pain; Assessment; Management; Medications; Cariac Arrest; and Sources of Information. Reference cards:
Initial Management of Chest Pain
Basic Life Support
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan Health professional’s role, knowledge, preferences and professional experience Policies and resources available within the RACF Requirements of local professional registration and regulatory bodies Relevant local legislation.
About Cardiac Chest Pain
Although chest pain is a symptom of a wide variety of diseases, coronary artery disease (CAD) accounts for 10-34% chest pain in the general population, and 50% chest pain in adults aged over 50 years [1, 2].
Coronary artery disease is the leading cause of death in adults. Twenty-seven percent of males and 17% of females aged 65-75 years have CAD, and the prevalence is higher after 75 years of age [3]. Ten percent of individuals with CAD first present with unstable angina; 60% of Australians admitted to hospital with unstable angina are aged over 65yrs [4].
Chest pain related to CAD is a significant health problem for RACF residents, and is a common reason for presentation to hospital Emergency Departments. Older adults have a higher risk of multi-vessel CAD and an adverse outcome from chest pain; the risk increases dramatically after age 70 [5]. Older adults, particularly those with diabetes, are more likely to have atypical signs and symptoms of cardiac pain [5-8].
This Clinical Information Sheet is about chest pain due to stable angina and acute coronary syndromes (ACS). These syndromes are attributable to myocardial ischaemia secondary to coronary obstruction. The underlying pathology is usually coronary atherosclerosis. Smoking, hyperlipidemia, hypertension, obesity and diabetes mellitus are risk factors that accelerate coronary atherosclerosis [6, 7, 9, 10].
Stable Angina
The underlying problem in stable angina is chronic, slowly progressive obstructive coronary atherosclerosis that restricts myocardial blood flow. Angina signals temporary myocardial ischaemia when exercise or emotional stress creates a demand for more blood flow.
In stable angina, onset of symptoms is sudden, subsides promptly with rest, and usually bears a predictable relationship to activities involving effort or stress.
Effort angina is categorised as stable if, for at least the past month, angina has been precipitated by the same amount of exertion. This usually means toleration of the usual level of activity and no rest pain apart from emotional stress [6, 7, 9, 10].
Precipitants, aggravating factors or alternative diagnoses which should be considered for stable angina include anaemia, obesity, aortic stenosis, hypertension, thyrotoxicosis and hypertrophic cardiomyopathy [10].
Acute Coronary Syndromes
In acute coronary syndromes (ACS) an atherosclerotic plaque in a coronary artery abruptly becomes active with endothelial rupture, vasoconstriction, platelet adhesion, thrombosis and/or inflammation. Over about two months, the plaque becomes less active, and the initially increased risk of MI, arrhythmia and death settles back to the previous level [10].
Initial clinical manifestations and risk change over a short time period, depending on the extent of thrombosis, distal platelet and embolism and resultant myocardial necrosis. Therefore clinical findings and investigations should be monitored to categorise syndromes and determine best treatment options, including medication and/or revascularisation interventions [10].
The acute coronary syndromes are differentiated on the basis of extent and duration of chest pain, ECG changes and biochemical markers. They are differentiated into unstable angina and acute myocardial infarction – STEMI and NSTEMI [6, 7, 9, 10].
STEMI (ST elevation myocardial infarction) is associated with ST elevation on the ECG.
NSTEMI (non-ST elevation myocardial infarction) has no ST elevation, and is associated with either ST depression, T-wave inversion or no changes on the ECG. NSTEMI is differentiated from unstable angina by biochemical evidence of myocardial necrosis. An elevated troponin above the 99th percentile of the local reference range is taken to indicate a myocardial infarction.
Unstable angina and NSTEMI represent a continuum and their management is similar [10].
Assessment
Diagnosis of cardiac chest pain
Typical cardiac chest pain includes [1, 3-6, 8, 9, 11-13]:
Substernal chest pressure or heaviness Pain described as squeezing, pressing, constricting, bursting, as a band around chest or as a weight on chest Deep but poorly localised Radiating to left arm, neck or jaw Nausea Diaphoresis Fear or feeling of impending doom Pain relieved by rest or nitroglycerin (NTG)
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Brought on by physical exertion or emotional stress Pain lasts 2-10 mins and rarely longer than 30 mins Shortness of breath Pallor Pain not reproducible by palpation Dizziness Significant change in pulse
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Some individuals, particularly older adults and/or diabetics, present with atypical signs and symptoms including [5-8]:
Lack of chest pain but pain related to exertion or stress radiating to left arm, neck or jaw Epigastric discomfort related to exertion or stress Unexplained fatigue Sharp stabbing pain
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In order to decide whether a resident with chest pain has a cardiac condition requiring urgent medical attention, assess [1, 4, 5, 11-13]:
Time of onset of pain; Position of pain including any radiation; Description of pain; Severity of pain; Length of pain episode; Frequency of pain episode; Any accompanying signs and symptoms; What precipitated the pain; If anything exacerbates the pain; and If anything relieves the pain.
Differential diagnoses
Assessing nature of the pain and the likely cause will help determine the most appropriate management. Differential diagnoses of chest pain include [1, 14]:
Cardiovascular causes e.g. myocardial infarction, unstable angina, aortic dissection, aortic aneurysm, pericarditis, aortic stenosis, mitral valve prolapse. Respiratory causes e.g. pulmonary embolism, pneumothorax, severe pneumonia Gastrointestinal causes e.g. oesophageal spasm or rupture, perforated peptic ulcer, gastric reflux, indigestion Musculoskeletal causes Psychiatric causes Trauma, neoplasm.
Assessment of pain type and referral, and response of pain to various interventions is important in differentiating between cardiac and non-cardiac chest pain [1, 14]. The following table outlines the general characteristics of different types of pain.
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Cause of pain
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Referred Pain
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Tenderness
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Response to positioning
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Response to food/fluid
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Response to NTG
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ischaemic cardiac
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Yes
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No
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No
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No
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Yes
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Non- ischaemic cardiac
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Yes
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No
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No
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No
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Yes
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pulmonary
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Usually No
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Usually No
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No
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No
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No
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pneumothorax
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No
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No
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Yes
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No
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No
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musculoskeletal
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No
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Yes
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Yes
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No
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No
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gastrointestinal
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Sometimes
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No
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No
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Yes
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No
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aortic aneurysm
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Yes
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No
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No
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No
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No
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psychiatric
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No
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No
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No
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No
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No
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Table from: L. Erhardt, J. Herlitz, L. Bossaert, et al., Task force on the management of chest pain. Eur Heart J, 2002. 23(15): p. 1153-1176.
Risk of adverse outcome
The risk of an adverse outcome (e.g. death or AMI) following a cardiac event is determined by the resident’s signs and symptoms and existing risk factors of severe CAD.
High risk
Patients who present with severe and prolonged chest pain lasting (> 20 mins); chest pain at rest or minimal activity; severe dyspnoea; rales; loss of consciousness; hypotension; cyanosis; tachycardia or bradycardia; positive cardiac markers and/or ECG changes and who are aged over 75 years have a high risk of an immediate severe outcome [4, 5, 8, 11]. For these residents, the 30-day rate of death or AMI is 12-30%.
Intermediate risk
Patients who are aged over 70 years or have a past history of prior AMI, cardiovascular or peripheral vascular disease, or those who present with prolonged chest pain lasting (> 20 mins); chest pain at rest that responds to treatment (e.g. rest or sublingual nitroglycerin) and borderline ECG or cardiac marker results have a medium risk of an adverse outcome [4, 5, 8]. For these residents the 30-day rate of death or AMI is 4-8% [8]. These patients are usually monitored for 6 hours until they are stable, then assessed and managed medically, unless their condition worsens [8].
Low risk
Patients who present with neither prolonged (> 20mins) chest pain nor chest pain at rest and have a normal (or unchanged from previous) ECG have a low risk of an adverse outcome [4, 5]. The 30-day rate of death or AMI is <2% [8]. These patients are usually managed by the GP with a focus on medical management and reduction of lifestyle risk factors [8].
Management
Management of residents with Coronary Artery Disease
Education
All residents with a history of angina should be encouraged to report symptoms to the RACF staff as soon as they occur. RACF staff should be provided with ongoing education on assessment and management of chest pain; use of medications related to the treatment of angina; and the importance of contacting emergency services as soon as possible if a resident is experiencing unstable angina [2, 4, 5, 11, 12, 15].
Advance Care Plan
It is recommended that residents diagnosed with cardiac conditions be given the opportunity to discuss their long term care options and preferences. The GP, residential care staff, resident and relatives should work together to develop a plan for caring for the resident as chronic disease progresses. Development of advance care plans is discussed in detail in the Clinical Information Sheet on Advance Care Planning.
Medication Advisory Committee
The Medication Advisory Committee should consider including aspirin and nitroglycerin on a “nurse-initiated medications” list (refer to Clinical Information Sheet on Medication Management) for the prompt management of cardiac chest pain. The Medication Advisory Committee should develop clear guidelines for the use of these medications in the management of unstable angina and/or AMI. The RACF should develop policies and procedures to ensure adequate stock of nurse-initiated medications, including a stock rotation system to ensure medications do not expire.
Stable Angina
Treat chest pain as stable angina when the [4-6, 8, 9]:
Resident has a previous diagnosis of angina; and Angina has a predictable onset and intensity; and Angina can be prevented or controlled with rest and/or administration of NTG.
The aims of treatment are to [13]:
Long term management involves assessment of the occurrence of pain in relation to the resident’s lifestyle. Risk factors including hypertension, smoking, hyperlipidemia, obesity and diabetes mellitus should be assessed and managed appropriately. Advice should be given regarding regular moderate exercise and avoidance of heavy, sudden and unaccustomed exertion and acute emotional stress where practicable. Further investigation should be considered for all residents presenting with chest pain, particularly if there is doubt regarding diagnosis or unsatisfactorily response to medical treatment. Early revascularisation therapy should be considered on an individual basis.
Drug therapy should be initiated immediately. The resident should be instructed to cease activities as soon as pain is felt and to shorten the attack, use:
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glycerol trinitrate spray 400 micrograms metered dose sublingually, repeat the dose once after 5 minutes if pain persists (maximum of 2 metered doses)
OR
glyceryl trinitrate tablet 300 to 600 micrograms sublingually, repeat every 3 to 5 minutes to a maximum of 1800 micrograms
OR
isosorbide dinitrate 5 mg sublingually, repeat every 5 minutes if pain persists, up to a maximum of 3 tablets.
Avoid nitrates if the patient has used sildenafil (Viagra) in the previous 24 hours or tadalafil (Cialis) in the previous five days.
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Acute Coronary Syndromes (Unstable Angina and Acute Myocardial Infarction – NSTEMI and STEMI)
Patients presenting with rest pain or severe exacerbation of stable angina require immediate risk assessment, usually in hospital [10], unless stated otherwise in the advance care plan.
Once the resident is transferred to the emergency department, further diagnostic tests will be conducted to confirm the diagnosis and determine the resident’s prognosis and management strategies [4, 5].
Electrocardiogram (ECG)
An electrocardiogram (ECG) is an electrical recording of the heart and is crucial in the diagnosis of unstable angina and AMI [4, 5, 7]. The ECG results are particularly valuable if recorded whilst symptoms are occurring and if the resident has previous ECGs for comparison [8]. If the resident is confirmed to have angina related to ACS treatment needs to be initiated immediately [8].
Cardiac Markers
Cardiac markers refers to proteins (e.g. creatine kinase, cardiac troponins, myoglobin) released following ischaemia of heart muscle [4, 5, 8]. Blood tests are usually conducted to detect early cardiac markers which are increased within 6 hours after onset of symptoms. Further blood tests are conducted to detect definitive cardiac markers which are increased 6-9 hours after onset of symptoms. Cardiac marker levels have a high sensitivity and specificity for AMI, and remain abnormal for several days [16].
STEMI
When thrombus completely occludes the coronary artery the result is severe transmural myocardial ischaemia with ST elevation on the ECG. This may cause sudden death from ventricular fibrillation. If the coronary occlusion is not relieved, myocardial infarction develops progressively over the next 6 to 12 hours [10, 13].
The aim of emergency treatment of STEMI is to [10]:
With STEMI it is important to reopen the artery and re-establish flow as soon as possible. Reperfusion therapy should be delivered as soon as feasible, usually within 30 minutes of arrival in hospital. Reperfusion may be achieved by the administration of thrombolytic therapy or by primary percutaneous intervention (PCI). Thrombolytic therapy consists of a combination of fibrinolytic agent, an antiplatelet agent, and an antithrombin. [10].
Managing Cardiac Chest Pain
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Procedure for Managing Cardiac Chest Pain
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1. |
Provide the resident with reassurance. Increased anxiety can worsen the symptoms [1, 2]. |
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2. |
Return the resident to bed, preferably in an upright position [7, 9]. |
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3. |
Administer oxygen 2-4L via nasal cannula [2, 7, 9, 12]. |
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4. |
Assess and record the resident’s vital signs [2, 5, 9].
Heart rate – take on both arms, assess for bruits, irregularities or unequal pulses Blood pressure – take on both arms Respiration – assess for rales in lungs Temperature
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5. |
Assess and record the frequency and severity of angina pain [9]. |
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6. |
6. For chest pain, administer sublingual NTG as prescribed by the resident’s GP on the medication chart [2, 3, 7, 9, 12, 13, 15, 17] Check that the medication has not expired, is labelled with the resident’s details and has been stored appropriately before administration. The patient should sit or lie down, particularly when first using NTG because of the possibility of hypotension. |
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7. |
Reassess the frequency and severity of the resident’s angina pain within 1-3 minutes [9]. |
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8. |
Repeat administration of sublingual NTG after 5 minutes if the resident’s pain has not resolved. Apply oxygen mask (6-10L) if the resident has increasing shortness of breath [9]. |
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9. |
Reassess the frequency and severity of the resident’s angina pain within 1-3 minutes [9]. |
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10. |
Repeat administration of sublingual NTG after 5 minutes if the resident’s pain has not resolved. |
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11. |
If the resident’s pain has not resolved after 3 doses of anti-anginal medication or 20 minutes immediately contact an ambulance unless there are alternative instructions in the resident’s advance care plan) [1-3, 5, 7, 9, 15]. |
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12. |
12. Administer aspirin as prescribed by the resident’s GP or as a nurse-initiated medication unless it is contraindicated [1, 2, 4, 7, 12, 17]. Check that the medication has not expired, is labelled with the resident’s details and has been stored appropriately before administration. If possible the resident should chew the medication [1, 2, 4, 7, 12]. |
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13. |
13. For persisting chest pain, administer analgesia as prescribed by the resident’s GP [1, 2, 7, 17]. Check that the medication has not expired, is labelled with the resident’s details and has been stored appropriately before administration. Where an order is available, morphine sulphate is recommended for relieving chest pain as it has both analgesic and anxiolytic properties [1, 7, 17]. |
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14. |
Reassess the resident 5-minutely until ambulance services arrive. |
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15. |
Provide the resident with reassurance, promote comfort and maintain airway whilst awaiting ambulance services [1]. |
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16. |
Provide the ambulance service with the resident’s medical history, time of onset of pain, characteristics of pain, treatment initiated and the resident’s response to treatment. |
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17. |
Document and communicate to other staff members and the resident’s GP and next-of-kin according to the RACF’s policy. |
Medications
Aspirin
Acetylsalicylic acid (aspirin) should be administered as soon as possible when a resident is suspected of suffering from acute coronary syndrome unless a clear contraindication exists (e.g. active bleeding) [4, 5, 13, 17-19]. Dosage is 160-325mg (non-enteric coated) aspirin. Where possible the resident should be instructed to chew the aspirin for quicker absorption [2, 4, 5, 12, 13, 17, 18].
Aspirin is recommended as a first line treatment in preventing and reducing fatality from AMI. Aspirin has anti-thrombotic effects – it reduces the formation of blood clots thereby reducing the risk of arterial blood flow occlusion [18, 19]. Administering aspirin within 24 hours of AMI significantly lowers the risk of further signs and symptoms over the following month [18], and decreases the fatality rate by as much as 50% [1, 2, 19].
Aspirin is continued in the ongoing medical management of residents with CAD as it provides a prophylactic anti-thrombotic effect that reduces risk of acute cardiac episodes. Dose is usually commenced at 150mg of aspirin daily, and may be decreased to 75 mg daily one month following an AMI [18, 19].
Nitroglycerin
All patients with angina should have an order for sublingual nitroglycerin (NTG) [3-5, 15, 17, 20]. Sublingual NTG becomes effective within 1-3 minutes. It may be administered every 5-minutes for up to 3 doses. If the resident’s angina has not resolved after 3 doses of 15-20minutes, the ambulance service should be contacted immediately [3-5, 15, 17, 20].
Nitroglycerin dilates arteries, increasing the coronary artery blood flow [15]. It is used to control symptoms by either relieving angina, or preventing it when undertaking activities known to provoke angina (e.g. climbing stairs) [13, 20].
Nitroglycerin (NTG) comes in a sublingual tablet and a mouth spray, used for quick relief of symptoms. Sublingual tablets should be placed under the resident’s tongue, or between the gum and cheek, and allowed to dissolve. The tablet should not be swallowed [20]. Nitroglycerin (NTG) spray should be administered by holding the spray close to the resident’s open mouth and administering one spray underneath the resident’s tongue [20].
Nitroglycerin (NTG) is also used in the ongoing management of angina, in the form of a buccal tablet or extended release tablet or a tansdermal patch [20]. The commonly used regimen of isosorbide dinitrate 3 or 4 times daily results in rapid development of tolerance. Sustained-release isosorbide mononitrate administered once-daily, or a glyceryl trinitrate patch worn for less than 16 hours per day, reduces this complication by allowing a nitrate-free period. [13].
Cardiac Arrest
Cardiac arrest, is said to have occurred where the patient is unconscious and not breathing [21]. Checking of carotid pulse is no longer recommended as it is incorrectly identified in 50% of cases, and performing cardiac compressions add no additional risk even if pulse is present [22].
Cardiac arrest may develop quickly, or after a prolonged period of decreased oxygen supply to the cardiac tissues. Cardiopulmonary resuscitation (CPR), a technique used to revive a patient experiencing cardiac arrest through heart compression and lung inflation, is indicated where there has been an abrupt and potentially reversible cessation of cardiac and or respiratory function [9, 21]. CPR should only be initiated by staff members who have received competency training in the technique [9]. Refer to the Reference Card: Basic Life Support.
Rate of survival following cardiac arrest and initiation of CPR is related to the type of arrhythmia, duration of arrest, time taken to initiate resuscitation and the age of the patient, with those aged over 70 having a significantly lower chance of survival. The most important modifiable factor is the time taken to initiate chest compressions and to initiaite defibrillation. Survival chances decrease to 0% if defibrillation takes longer than 8 minutes to initiate [22]. Survival rates to discharge following CPR in an acute hospital setting are reported to be approximately 22% [9].
Cardiac Compression Technique
Effectiveness of cardiac compressions is crucial in maximising survivial potential. Whilst the body is relatively efficient at extracting oxygen from the blood, cardiac compressions need to be performed effectively enough to circulate blood around the body [22]. The recommended point for compression is midline over the lower half of the sternum. To locate the compression point first locate the lower end of the sternum by running the fingers along the lower rib from the outside in until they meet in the middle. Locate the upper end of the sternum by feeling the groove between the collar bones. The mid point of the sternum is then located by extending the fingers equidistant to meet in the middle of the sternum. Place one thumb at this point, then apply the other hand in position on the lower half of the sternum [22, 23].
The heel of the hand should be placed in position with the fingers parallel to the ribs and slightly raised, then the other hand is placed securely on top of the first, locking the thumb around the wrist of the lower hand. Positioning of shoulders should be over the patient’s sternum and arms should remain straight. Use your body weight to exert pressure through the heel of the lower hand [24].
Compressions should be applied in a steady rhythm allowing equal time for compression and relaxation, depressing the sternum 4-5cms, or approximately one third of the depth of the patient’s chest [24]. Rate of compressions should be at least 60 compressions per minute, at a ratio of 30 compressions to 2 inflations [22].
Procedure for Cardiopulmonary Resuscitation
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Procedure for Cardiopulmonary Resuscitation
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1. |
Establish the resident is experiencing cardiac arrest [9, 21, 22].
Determine conscious state; Determine if resident is breathing
If assessing carotid pulse do so promptly (within 10 seconds) to prevent delay in commencing cardiac compressions.
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2. |
Call for assistance [9, 21]. |
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3. |
2nd person arriving on the scene [9, 22]:
Prepare oxygen and air viva. Stand at the patient’s head, facing the feet and maintain the airway in an open position by using both hands to tilt the patient’s head back and jaw thrust. Place mask over nose and mouth and press firmly to face, elevating jaw into mask to achieve a good seal. Attach air viva to mask and inflate lungs, observing for chest rise and listening for exhalation [25]. Assist with CPR in a ratio of 2 inflations:30 compressions
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4. |
3rd person arriving at the scene [9]:
Immediately contact and ambulance Time taken to commence chest compressions and defibrillation is a significant factor in survival rate [22]. Place board under resident Provide hands-on assistance as required.
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5. |
If the resident is not breathing, commence expired air resuscitation. Deliver 2 full inflations over 10 seconds on commencing [22].
If the resident has no pulse, commence CPR. A minimum of 100 compressions should be administered over one minute, using a ratio of 2 inflations to 30 compressions with 2 operators [22].
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6. |
Assess for signs of circulation after one minute but limit assessment time to 10 seconds. If there are no signs of recovery, continue CPR. If the resident has a spontaneous pulse present, continue expired air resuscitation until breathing returns whilst continuously monitoring radial or carotid pulse [22, 26].
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7. |
Continue CPR until:
There are signs of spontaneous circulation; or The resident recovers; or The ambulance arrives; or A medical doctor pronounces the resident dead; or Continuing CPR becomes impossible [22, 27].
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Sources of Information
Where to go for more information
Australian Resuscitation Council
The Australian Resuscitation Council develops, reviews and publishes nation-wide guidelines in consultation with member bodies and other experts. The ARC provides education and information for professionals and interested community members and participates in new emergency medicine research.
Contact: Tel: Victorian Branch (03) 5338 5000
Website: http://www.resus.org.au/
National Heart Foundation of Australia
The National Heart Foundation of Australia is a charity organisation that works in research, prevention and education related to cardiovascular disease. Qualified health information staff are available to provide information on a range of cardiovascular health issues, including surgery and other treatments, cardiac disease and conditions and rehabilitation following an AMI.
Contact: 1300 36 27 87
Website: http://www.heartfoundation.com.au/
Further Reading
Therapeutic Guidelines have been prepared by writing groups of experienced clinicians, and represent independent consensus opinion based on the evidence available at the time of publication. The guidelines are available from website at: www.tg.com.au
References
Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., Marcassa, C., Quinn, T., van Weert, H., Task force on the management of chest pain. Eur Heart J, 2002. 23(15): p. 1153-1176. National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand , Management of Unstable Angina Guidelines. Medical Journal of Australia, 2000. 173(supp): p. S64-S88. Scottish Intercollegiate Guidelines Network, Management of Stable Angina. 2001 National Health and Medical Research Council, Diagnosis and management of unstable angina. 1996, Canberra: Australian Government Publishing Service. Braunwald et al, Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction Update, in http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm (accessed April 2004), Cardiology, American College of and Association, American Heart. 2002 Fox, J., ed. Cardiology: Acute Coronary Syndromes (chapter 3). University of Iowa Family Practice Handbook, ed. Graber, M. and Lanternier, M. 2001, Mosby: Iowa. Fonarow, G., UCLA Chest Pain and Unstable Angina - Patient Management Guideline. 3rd ed. 2001, California: Regents of the University of California, Clinical Guideline Committee, UCLA Division of Cardiology. Guidelines and Protocols Advisory Committee, Evaluation of Acute Chest Pain for Acute Coronary Syndromes. 2003, Victoria, BC: British Columbia Medical Association. Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. eTG, Therapeutic Guidelines, in http://www.tg.com.au (accessed March 2004), eTG. 2004 Institute For Clinical Systems Improvement, Diagnosis of chest pain. 2002 Canadian Association of Emergency Physicians Rural and Small Urban Committee, Chest pain guideline and contionuous quality improvement system for the rapid recognition and initial management of acute myocardial infarction in Canadian rural emergency health care facilities. 1998 eTG, Therapeutic Guidelines: Cardiac, in http://www.tg.com.au (accessed August 2006), eTG. 2006 The Northern Hospital, Short Stay Chest Pain Unit Protocol. 2001 Ryan, T., Antman, E., Brooks, N., Califf, R., Hillis, L., Hiratzka, L. , Rapaport, E., Riegel, B., Russell, R. , Smith, E., Weaver, W., ACC/AHA guidelines for the management of patients with acute myocardial infarction: 1999 update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). in http://www.acc.org (accessed April 2004), American College of Cardiology and American Heart Association. 1999 Wu, A. , Apple, F., Gibler, W., Jesse, R. , Warshaw, M., Valdes, R., National Academy of Clinical Biochemistry Standards of Laboratory Practice: recommendations for the use of cardiac markers in coronary artery diseases. Clin Chem, 1999. 45(7): p. 1104-1121. Graber, M, ed. Emergency Medicine: The Management Of Acute Chest Pain In The Emergency Department Setting. 4th ed. University of Iowa Family Practice Handbook, ed. Graber, M. and Lanternier, M. 2001, Mosby: Iowa. Campbell,al, et, Aspirin for the secondary prophylaxis of vascular disease in primary care, in http://www.nelh.nhs.uk/guidelinesdb/html/aspirin-ft.htm#REC-AMI (accessed April 2004), Centre for Health Services Research University of Newcastle upon Tyne. 1997 Awtry, E.,Loscalzo, J., Aspirin. Circulation, 2000. 101(1206). nitroglycerin.com, Nitroglycerin, in http://www.nitroglycerin.com/, Anakena Internet Services, P.L. 2003 Australian Resuscitation Council, Policy Statement - Recognition of Cardiac Arrest. 2002 Australian Resuscitation Council, (ARC), Australian Resuscitation Guidelines: Applying the evidence and simplifying the process. Emerg Med Aust, 2006. 18(4): p. 317-321. Australian Resuscitation Council, Policy Statement - Locating the Site for External Cardiac Compression. 1997 Australian Resuscitation Council, Revised Policy Statement - External Cardiac Compression Technique - Adults. 2002 Australian Resuscitation Council, Policy Statement - Expired Air Resuscitation - Mouth to Mask Method. 1998 Australian Resuscitation Council, Policy Statement - Cardiopulmonary Resuscitation - Recovery Checks. 1996 Australian Resuscitation Council, Revised Policy Statement - Cardiopulmonary Resuscitation. 2002 National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
The information presented is developed from Level I evidence produced by the American College of Cardiology, American Heart Association, the National Health and Medical Research Council and Scottish Intercollegiate Guidelines Network. Information in this Clinical Information Sheet represents the most effective current management strategies for chest pain based on systematic review of the literature. Treatments are primarily drawn from the Therapeutic Guidelines: Cardiovascular 2003 (eTG April 2006). Information on resuscitation has been updated based on the Australian Resuscitation Council guidelines 2006.
The following table outlines the level of evidence of each reference:
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Reference |
Year |
Level of Evidence |
1. |
Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., Marcassa, C., Quinn, T., van Weert, H., Task force on the management of chest pain. Eur Heart J, 2002. 23(15): p. 1153-1176. |
2002 |
Level I evidence |
2. |
National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand , Management of Unstable Angina Guidelines. Medical Journal of Australia, 2000. 173(supp): p. S64-S88. |
2000 |
Level IV C evidence |
3. |
Scottish Intercollegiate Guidelines Network, Management of Stable Angina. 2001 |
2001 |
Level I evidence |
4. |
National Health and Medical Research Council, Diagnosis and management of unstable angina. 1996, Canberra: Australian Government Publishing Service. |
1996 |
Level I evidence |
5. |
Braunwald et al, Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction Update, in http://www.acc.org/clinical/guidelines/unstable/incorporated/index.htm (accessed April 2004), Cardiology, American College of and Association, American Heart. 2002 |
2004 |
Level I evidence |
6. |
Fox, J., ed. Cardiology: Acute Coronary Syndromes (chapter 3). University of Iowa Family Practice Handbook, ed. Graber, M. and Lanternier, M. 2001, Mosby: Iowa. |
2001 |
Level IV C evidence |
7. |
Fonarow, G., UCLA Chest Pain and Unstable Angina - Patient Management Guideline. 3rd ed. 2001, California: Regents of the University of California, Clinical Guideline Committee, UCLA Division of Cardiology. |
2001 |
Level IV C evidence |
8. |
Guidelines and Protocols Advisory Committee, Evaluation of Acute Chest Pain for Acute Coronary Syndromes. 2003, Victoria, BC: British Columbia Medical Association. |
2003 |
Level IV C evidence |
9. |
Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. |
2003 |
Level IV C evidence |
10. |
eTG, Therapeutic Guidelines, in http://www.tg.com.au (accessed March 2004), eTG. 2004 |
2004 |
Level IV C evidence |
11. |
Institute For Clinical Systems Improvement, Diagnosis of chest pain. 2002 |
2002 |
Level IV C evidence |
12. |
Canadian Association of Emergency Physicians Rural and Small Urban Committee, Chest pain guideline and contionuous quality improvement system for the rapid recognition and initial management of acute myocardial infarction in Canadian rural emergency health care facilities. 1998 |
1998 |
Level IV C evidence |
13. |
eTG, Therapeutic Guidelines: Cardiac, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
14. |
The Northern Hospital, Short Stay Chest Pain Unit Protocol. 2001 |
2001 |
Level IV C evidence |
15. |
Ryan, T., Antman, E., Brooks, N., Califf, R., Hillis, L., Hiratzka, L. , Rapaport, E., Riegel, B., Russell, R. , Smith, E., Weaver, W., ACC/AHA guidelines for the management of patients with acute myocardial infarction: 1999 update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). in http://www.acc.org (accessed April 2004), American College of Cardiology and American Heart Association. 1999 |
1999 |
Level I evidence |
16. |
Wu, A. , Apple, F., Gibler, W., Jesse, R. , Warshaw, M., Valdes, R., National Academy of Clinical Biochemistry Standards of Laboratory Practice: recommendations for the use of cardiac markers in coronary artery diseases. Clin Chem, 1999. 45(7): p. 1104-1121. |
1999 |
Level I evidence |
17. |
Graber, M, ed. Emergency Medicine: The Management Of Acute Chest Pain In The Emergency Department Setting. 4th ed. University of Iowa Family Practice Handbook, ed. Graber, M. and Lanternier, M. 2001, Mosby: Iowa. |
2001 |
Level IV C evidence |
18. |
Campbell,al, et, Aspirin for the secondary prophylaxis of vascular disease in primary care, in http://www.nelh.nhs.uk/guidelinesdb/html/aspirin-ft.htm#REC-AMI (accessed April 2004), Centre for Health Services Research University of Newcastle upon Tyne. 1997 |
2004 |
Level I evidence |
19. |
Awtry, E.,Loscalzo, J., Aspirin. Circulation, 2000. 101(1206). |
2000 |
Level IV C evidence |
20. |
nitroglycerin.com, Nitroglycerin, in http://www.nitroglycerin.com/, Anakena Internet Services, P.L. 2003 |
2003 |
Level V evidence |
21. |
Australian Resuscitation Council, Policy Statement - Recognition of Cardiac Arrest. 2002 |
2002 |
Level IV C evidence |
22. |
Australian Resuscitation Council, (ARC), Australian Resuscitation Guidelines: Applying the evidence and simplifying the process. Emerg Med Aust, 2006. 18(4): p. 317-321. |
2006 |
Level I evidence |
23. |
Australian Resuscitation Council, Policy Statement - Locating the Site for External Cardiac Compression. 1997 |
1997 |
Level IV C evidence |
24. |
Australian Resuscitation Council, Revised Policy Statement - External Cardiac Compression Technique - Adults. 2002 |
2002 |
Level IV C evidence |
25. |
Australian Resuscitation Council, Policy Statement - Expired Air Resuscitation - Mouth to Mask Method. 1998 |
1998 |
Level IV C evidence |
26. |
Australian Resuscitation Council, Policy Statement - Cardiopulmonary Resuscitation - Recovery Checks. 1996 |
1996 |
Level IV C evidence |
27. |
Australian Resuscitation Council, Revised Policy Statement - Cardiopulmonary Resuscitation. 2002 |
2002 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [28] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Cardiac Chest Pain
The following reference cards are designed to be used in conjunction with the Cardiac Chest Pain Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
Viewing Reference Cards
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Printing Reference Cards
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Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards:
Initial Management of Chest Pain
Basic Life Support
Downloads and Printing
See note on viewing and printing documents.
To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
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