Skip to main content
SpringerLink
Log in

Medical Therapy in Patients Managed in a Chest Pain Observation Unit

  • Chapter
  • First Online:
Short Stay Management of Chest Pain

Part of the book series: Contemporary Cardiology ((CONCARD))

  • 401 Accesses

Abstract

There are no randomized controlled trials that demonstrate that any medical therapy reduces adverse events in patients with undifferentiated chest pain evaluated in chest pain units (CPUs). Many of the millions of patients that present to the emergency department (ED) in the United States with chest pain are managed in CPUs, but the vast majority of these patients do not suffer an acute coronary syndrome (ACS). Studies have shown that only 2% of patients evaluated in CPUs are diagnosed with myocardial infarction (MI) (Newby et al., Am J Cardiol 85: 801–805, 2000; Farkouh et al., N Engl J Med, 339: 1882–1888, 1998). This chapter will address the role of aspirin, nitrates, anticoagulation, and beta-blockers in patients with undifferentiated chest pain managed in a CPU.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2:349–60.

    Google Scholar 

  2. Lewis HD Jr, Davis JW, Archibald DG, Steinke WE, Smitherman TC, Doherty JE III, et al. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study. N Engl J Med. 1983;309:396–403.

    Article  PubMed  Google Scholar 

  3. Cairns JA, Gent M, Singer J, Finnie KJ, Froggatt GM, Holder DA, et al. Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. N Engl J Med. 1985;313:1369–75.

    Article  CAS  PubMed  Google Scholar 

  4. Theroux P, Ouimet H, McCans J, Latour JG, Joly P, Levy G, et al. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med. 1988;319:1105–11.

    Article  CAS  PubMed  Google Scholar 

  5. The RISC Group. Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet. 1990;336:827–30.

    Article  Google Scholar 

  6. Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392:1036–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med. 1989;321:129–35.

    Article  Google Scholar 

  8. Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Article  Google Scholar 

  9. Fragmin during Instability in Coronary Artery Disease (FRISC) study group. Low-molecular-weight heparin during instability in coronary artery disease. Lancet. 1996;347:561–8.

    Article  Google Scholar 

  10. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755–62.

    Article  CAS  PubMed  Google Scholar 

  11. Gurfinkel EP, Manos EJ, Mejail RI, Cerda MA, Duronto EA, Garcia CN, et al. Low molecular weight heparin versus regular heparin or aspirin in the treatment of unstable angina and silent ischemia. J Am Coll Cardiol. 1995;26:313–8.

    Article  CAS  PubMed  Google Scholar 

  12. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e139–228.

    Article  PubMed  Google Scholar 

  13. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41:407–77.

    Article  PubMed  Google Scholar 

  14. Barbash IM, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, et al. Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration. Cardiology. 2002;98:141–7.

    Article  CAS  PubMed  Google Scholar 

  15. Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, et al. Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S315–67.

    Article  PubMed  Google Scholar 

  16. Telford AM, Wilson C. Trial of heparin versus atenolol in prevention of myocardial infarction in intermediate coronary syndrome. Lancet. 1981;1:1225–8.

    Article  CAS  PubMed  Google Scholar 

  17. Williams DO, Kirby MG, McPherson K, Phear DN. Anticoagulant treatment of unstable angina. Br J Clin Pract. 1986;40(3):114–6.

    CAS  PubMed  Google Scholar 

  18. Theroux P, Waters D, Qiu S, McCans J, de Guise P, Juneau M. Aspirin versus heparin to prevent myocardial infarction during the acute phase of unstable angina. Circulation. 1993;88:2045–8.

    Article  CAS  PubMed  Google Scholar 

  19. Neri Serneri GG, Gensini GF, Poggesi L, Trotta F, Modesti PA, Boddi M, et al. Effect of heparin, aspirin, or alteplase in reduction of myocardial ischaemia in refractory unstable angina. Lancet. 1990;335:615–8.

    Article  CAS  PubMed  Google Scholar 

  20. Holdright D, Patel D, Cunningham D, Thomas R, Hubbard W, Hendry G, et al. Comparison of the effect of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina. J Am Coll Cardiol. 1994;24:39–45.

    Article  CAS  PubMed  Google Scholar 

  21. Cohen M, Theroux P, Borzak S, Frey MJ, White HD, Van Mieghem W, et al. Randomized double-blind safety study of enoxaparin versus unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes treated with tirofiban and aspirin: the ACUTE II study. The Antithrombotic Combination Using Tirofiban and Enoxaparin. Am Heart J. 2002;144:470–7.

    Article  CAS  PubMed  Google Scholar 

  22. Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337:447–52.

    Article  CAS  PubMed  Google Scholar 

  23. Klein W, Buchwald A, Hillis SE, Monrad S, Sanz G, Turpie AG, et al. Comparison of low-molecular-weight heparin with unfractionated heparin acutely and with placebo for 6 weeks in the management of unstable coronary artery disease. Fragmin in unstable coronary artery disease study (FRIC). Circulation. 1997;96:61–8.

    Article  CAS  PubMed  Google Scholar 

  24. The Frax.I.S. Study Group. Comparison of two treatment durations (6 days and 14 days) of a low molecular weight heparin with a 6-day treatment of unfractionated heparin in the initial management of unstable angina or non-Q wave myocardial infarction: FRAX.I.S. (FRAxiparine in Ischaemic Syndrome). Eur Heart J. 1999;20:1553–62.

    Article  Google Scholar 

  25. Goodman SG, Fitchett D, Armstrong PW, Tan M, Langer A. Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) Trial Investigators. Randomized evaluation of the safety and efficacy of enoxaparin versus unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes receiving the glycoprotein IIb/IIIa inhibitor eptifibatide. Circulation. 2003;107:238–44.

    Article  CAS  PubMed  Google Scholar 

  26. Blazing MA, de Lemos JA, White HD, Fox KA, Verheugt FW, Ardissino D, et al. Safety and efficacy of enoxaparin vs unfractionated heparin in patients with non-ST-segment elevation acute coronary syndromes who receive tirofiban and aspirin: a randomized controlled trial. JAMA. 2004;292:55–64.

    Article  CAS  PubMed  Google Scholar 

  27. Antman EM, McCabe CH, Gurfinkel EP, Turpie AG, Bernink PJ, Salein D, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. 1999;100:1593–601.

    Article  CAS  PubMed  Google Scholar 

  28. Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL, Goodman S, et al. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA. 2004;292:45–54.

    CAS  PubMed  Google Scholar 

  29. Stone GW, McLaurin BT, Cox DA, Bertrand ME, Lincoff AM, Moses JW, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006;355:2203–16.

    Article  CAS  PubMed  Google Scholar 

  30. Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators, Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006;354:1464–76.

    Article  Google Scholar 

  31. Petersen JL, Mahaffey KW, Hasselblad V, Antman EM, Cohen M, Goodman SG, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004;292:89–96.

    Article  CAS  PubMed  Google Scholar 

  32. Peterson ED, Roe MT, Rumsfeld JS, Shaw RE, Brindis RG, Fonarow GC, et al. A call to ACTION (Acute Coronary Treatment and Intervention Outcomes Network): a national effort to promote timely clinical feedback and support continuous quality improvement for acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2009;2:491–9.

    Article  PubMed  Google Scholar 

  33. Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114(8):774–82.

    Article  PubMed  Google Scholar 

  34. Yusuf S, Collins R, MacMahon S, Peto R. Effect of intravenous nitrates on mortality in acute myocardial infarction: an overview of the randomised trials. Lancet. 1988;1:1088–92.

    Article  CAS  PubMed  Google Scholar 

  35. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. Lancet. 1995;345:669–85.

    Article  Google Scholar 

  36. Gruppo Italiano per lo Studio della Sopravvivenza nell’infarto Miocardico. GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet. 1994;343:1115–22.

    Google Scholar 

  37. Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med. 2003;139:979–86.

    Article  PubMed  Google Scholar 

  38. Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain. Ann Emerg Med. 2005;45:581–5.

    Article  PubMed  Google Scholar 

  39. Roberts R, Rogers WJ, Mueller HS, Lambrew CT, Diver DJ, Smith HC, et al. Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study. Circulation. 1991;83:422–37.

    Article  CAS  PubMed  Google Scholar 

  40. Van de Werf F, Janssens L, Brzostek T, Mortelmans L, Wackers FJ, Willems GM, et al. Short-term effects of early intravenous treatment with a beta-adrenergic blocking agent or a specific bradycardiac agent in patients with acute myocardial infarction receiving thrombolytic therapy. J Am Coll Cardiol. 1993;22:407–16.

    Article  PubMed  Google Scholar 

  41. Freemantle N, Cleland J, Young P, Mason J, Harrison J. beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999;318:1730–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366:1622–32.

    Article  CAS  PubMed  Google Scholar 

  43. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA. 1988;260:2259–63.

    Article  CAS  PubMed  Google Scholar 

  44. Ellis K, Tcheng JE, Sapp S, Topol EJ, Lincoff AM. Mortality benefit of beta blockade in patients with acute coronary syndromes undergoing coronary intervention: pooled results from the Epic, Epilog, Epistent, Capture and Rapport Trials. J Interv Cardiol. 2003;16:299–305.

    Article  PubMed  Google Scholar 

  45. Newby LK, Kaplan AL, Granger BB, Sedor F, Califf RM, Ohman EM. Comparison of cardiac troponin T versus creatine kinase-MB for risk stratification in a chest pain evaluation unit. Am J Cardiol. 2000;85:801–5.

    Article  CAS  PubMed  Google Scholar 

  46. Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med. 1998;339:1882–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Wayne State University, Detroit, MI, USA

    James McCord

  2. Division of Cardiology, Henry Ford Heart and Vascular Institute, Detroit, MI, USA

    James McCord

  3. Division of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA

    Ahmed Kazem

Authors
  1. James McCord
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed Kazem
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ahmed Kazem .

Editor information

Editors and Affiliations

  1. School of Medicine, Wayne State University, Grosse Pointe Park, MI, USA

    Margarita Pena

  2. School of Medicine, Emory University, Decatur, GA, USA

    Anwar Osborne

  3. Baylor College of Medicine, Houston, TX, USA

    W. Frank Peacock

Rights and permissions

Reprints and permissions

Copyright information

© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

McCord, J., Kazem, A. (2022). Medical Therapy in Patients Managed in a Chest Pain Observation Unit. In: Pena, M., Osborne, A., Peacock, W.F. (eds) Short Stay Management of Chest Pain. Contemporary Cardiology. Humana, Cham. https://doi.org/10.1007/978-3-031-05520-1_13

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-05520-1_13

  • Published:

  • Publisher Name: Humana, Cham

  • Print ISBN: 978-3-031-05519-5

  • Online ISBN: 978-3-031-05520-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation