3. Overview
• Chest pain is a hallmark symptom for the diagnosis of Acute Myocardial Infarction
(AMI) or heart attack.
• AMI is a life-threatening condition occurring when there is sudden blockage in the blood
supplying to itself leading to the damage of the heart muscle and eventually alters its
function (Heart Foundation, 2016).
• It is medical emergency and categorized as code Blue.
• An immediate clinical management is necessary, so it falls under Australian triage
category 2 and treated with high priority (clinical care is to be initiated within 10
minutes) (Pallas, 2014).
• Location: central chest radiating to neck, jaw, shoulder and left arm
3
4. Statistics
• According to the overall result from more than 190 countries reveals that the heart
disease is number one global cause for death with 17.3 million deaths every year
(American Heart Association, 2015).
• There is significantly higher incidence of heart disease in the western society (Pallas,
2014).
• In Australia, the estimation of over 350,000 people had heart attack at some stages of
their lives. More than 100,000 Australians are reported to have heart attack under 65
years of age. In 2012/13, 54,000 hospitalizations were due to heart attack which is
elevated by 15% from 2003/2004. In addition, the deaths from heart attack accounted
8,611 in 2013, in general, 24 deaths every day (Heart Foundation, 2016).
4
5. Assessment
Initial Assessment
• Full set of vital signs (HR, BP, RR, O2Sats, Temp)
• Baseline neurological assessment (GCS)
• Brief patient history (presenting s/s, medical history, current medications and
allergies, risk factors like HTN, obesity, high cholesterol)
• Brief physical examination (Look, Listen and Feel)
• Pain assessment (PQRST)
(Pallas, 2014)
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6. NSW Chest Pain Pathway
Uniform guide for any patient with
chest pain presenting to NSW
hospitals
2 versions dependent on PCI
capability with (John Hunter) and
without (Maitland, Belmont, Mater)
(NSW Health, 2011)
6
8. General Management
Cardiac monitoring (Telemetry)
Troponin (myocardial damage, detected in blood stream even after 2-4 hours of myocardial
injury), normal level <0.01ng/ml but in chest pain its >/=0.01 ng/ml detecting cardiac injury
(Martinez, & Bucher, 2014)
ECG
• Most important diagnostic tool for chest pain
• ST elevation (inflammation), pathological Q wave (myocardial necrosis), T wave inversion
(acute ischemia), left bundle branch block
Routine blood tests
• FBC, EUC, LFT
(Pallas, 2014)
8
9. General Management
Oxygen therapy
• Although supplemental oxygen is recommended practice for years, the supporting evidence is
inconsistent.
• Recent evidence reflects associated risk of hyper-oxygenation of ACS patient with normal
oxygen saturation can outweigh potential benefit
• The Australian Resuscitation Council in 2011 recommends oxygen to be used for managing
breathlessness/ hypoxia instead of routine treatment of chest pain (Pallas, 2014).
β-adrenergic blockers
• Decrease myocardial demand by the reduction of HR, BP and contractility
• Use in first hours is evident to reduce infarction size and incidence of complication
(Gallagher, & Driscoll, 2012)
9
10. General Management
IV access (2 IV lines)
• Rapid administration of medications
• Venous blood gas (respiratory distress/ palpitations)
Chest X-ray
• Physical abnormalities, pulmonary oedema, pneumonia, pneumothorax, rib fracture
Pain relief
• Glyceryl trinitrate (GTN) (dilates coronary blood vessels), 300-600 mcg sublingual GTN
• Narcotics (Morphine) (vasodilators)
(Pallas, 2014)
10
11. Thrombolytic and Reperfusion
Anti-thrombotic drug
• Aspirin, single dose of 300 mg in ED
Reperfusion therapy
• Tenecteplase, Reteplase (tissue type plasminogen activators)
• Activates plasminogen presented in blood clots, so the risk of
haemorrhage is minimized
(Pallas, 2014)
11
12. Summary
• Chest pain in a medical emergency
• Early management is essential for preserving life
• Brief assessment is required to underline predisposing factors
• NSW chest pain pathway is guided to plan the management actions
• Regular monitoring of the patient is essential
12
13. References
• American Heart Association. (2015). American Heart Association statistical report tracks global figures for first time.
Retrieved from http://news.heart.org/american-heart-association-statistical-report-tracks-global-figures-first-time/
• Gallagher, R. & Driscoll, A. (2012). Cardiovascular alterations and management. In D. Elliott, L. Aitken, & W.
Chaboyer (Eds), ACCCN's Critical Care Nursing. Elsevier Australia. Retrieved from https://www-elsevier-elibrary-com
• Heart Foundation. (2016). Heart attack fact sheet. Retrieved from http://heartfoundation.org.au/about-us/what-we-
do/heart-disease-in-australia/heart-attack-fact-sheet
• Jaturawutthichai, P. (2016). ECG of ST elevation myocardial infarction ( STEMI ) and detail of ECG ( P wave , PR
segment , PR interval , QRS complex , QT interval , ST elevate , T wave ) Acute coronary syndrome , angina pectoris.
Retrieved from http://www.shutterstock.com/pic-403308256/stock-vector-ecg-of-st-elevation-myocardial-infarction-
stemi-and-detail-of-ecg-p-wave-pr-segment-pr.html
• Martinez, L. G. & Bucher, L. Adapted by Gallagher, R. (2014). Nursing Management: coronary artery disease and acute
coronary syndrome. In D. Brown & H. Edwards (Eds), Lewis's Medical-Surgical Nursing: Assessment and Management
of Clinical Problems. Elsevier, Australia. Retrieved from https://www-elsevier-elibrary-com 13
14. NSW Health. (2011). Chest Pain Evaluation (NSW Chest Pain Pathway).
Retrieved from
http://www0.health.nsw.gov.au/policies/pd/2011/pdf/pd2011_037.pdf
Pallas, J. (2014). Managing chest pain in emergency department: A resource for
emergency nurses. Retrieved from
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0017/142163/Managi
ng_chest_pain_package_2014.pdf
