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))

  • 755 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 departments (EDs) 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(7):801–5, 2000; Farkouh et al. N Eng J Med 339(26):1882–8, 1998). This chapter will address the role of aspirin (ASA), nitrates, heparin, and beta blockers in the patients with undifferentiated chest pain in the 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 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 219.00
Price excludes VAT (USA)
  • Compact, lightweight 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. 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 Aug 13;2(8607):349–60.

    Google Scholar 

  2. Lewis HD, Jr., Davis JW, Archibald DG, Steinke WE, Smitherman TC, Doherty JE, 3rd, et al. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study. The New England Journal of Medicine. 1983 Aug 18;309(7):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. The New England Journal of Medicine. 1985 Nov 28;313(22):1369–75.

    Article  PubMed  CAS  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. The New England Journal of Medicine. 1988 Oct 27;319(17):1105–11.

    Article  PubMed  CAS  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 Oct 6;336(8719):827–30.

    Article  Google Scholar 

  6. Steering Committee of the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing Physicians' Health Study. The New England Journal of Medicine. 1989 Jul 20;321(3):129–35.

    Article  Google Scholar 

  7. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ (Clinical Research) ed. 2002 Jan 12;324(7329):71–86.

    Google Scholar 

  8. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Journal of the American College of Cardiology. 1988 Dec;12(6 Suppl A):3A–13A.

    Google Scholar 

  9. Low-molecular-weight heparin during instability in coronary artery disease, Fragmin during Instability in Coronary Artery Disease (FRISC) study group. Lancet. 1996 Mar 2;347(9001):561–8.

    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 Jun 13;351(9118):1755–62.

    Article  PubMed  CAS  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. Journal of the American College of Cardiology. 1995 Aug;26(2):313–8.

    Article  PubMed  CAS  Google Scholar 

  12. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Jr., et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Journal of the American College of Cardiology. 2007 Aug 14;50(7):e1–e157.

    Article  PubMed  Google Scholar 

  13. Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, et al. Task force on the management of chest pain. European Heart Journal. 2002 Aug;23(15):1153–76.

    Article  PubMed  CAS  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(3):141–7.

    Article  PubMed  CAS  Google Scholar 

  15. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005 Dec 13;112(24 Suppl):IV1–203.

    Google Scholar 

  16. Telford AM, Wilson C. Trial of heparin versus atenolol in prevention of myocardial infarction in intermediate coronary syndrome. Lancet. 1981 Jun 6;1(8232):1225–8.

    Article  PubMed  CAS  Google Scholar 

  17. Williams DO, Kirby MG, McPherson K, Phear DN. Anticoagulant treatment of unstable angina. The British Journal of Clinical Practice. 1986 Mar;40(3):114–6.

    PubMed  CAS  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 Nov;88(5 Pt 1):2045–8.

    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 Mar 17;335(8690):615–8.

    Article  PubMed  CAS  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. Journal of the American College of Cardiology. 1994 Jul;24(1):39–45.

    Article  PubMed  CAS  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. American Heart Journal. 2002 Sep;144,(3):470–7.

    Article  PubMed  CAS  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. The New England Journal of Medicine. 1997 Aug 14;337(7):447–52.

    Article  PubMed  CAS  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 Jul 1;96(1):61–8.

    PubMed  CAS  Google Scholar 

  24. 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). European Heart Journal. 1999 Nov;20(21):1553–62.

    Article  PubMed  Google Scholar 

  25. Goodman SG, Fitchett D, Armstrong PW, Tan M, Langer A. 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 Jan 21;107(2):238–44.

    Article  PubMed  CAS  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 Jul 7;292(1):55–64.

    Article  PubMed  CAS  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 Oct 12;100(15):1593–601.

    CAS  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 Jul 7;292(1):45–54.

    Article  PubMed  CAS  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 Nov 23; 355(21):2203–16.

    Article  PubMed  CAS  Google Scholar 

  30. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, Granger CB, et al. Comparison of Fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006 Apr 6; 354(14):1464–76.

    Article  PubMed  CAS  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 Jul 7;292(1):89–96.

    Article  PubMed  CAS  Google Scholar 

  32. Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005 Dec 28;294(24):3108–16.

    Article  PubMed  CAS  Google Scholar 

  33. 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 May 14;1(8594):1088–92.

    Article  PubMed  CAS  Google Scholar 

  34. 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. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. Lancet. 1995 Mar 18;345(8951):669–85.

    Article  Google Scholar 

  35. GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto Miocardico. Lancet. 1994 May 7;343(8906):1115–22.

    Google Scholar 

  36. 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. Annals of internal medicine. 2003 Dec 16;139(12):979–86.

    PubMed  Google Scholar 

  37. 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. Annals of emergency medicine. 2005 Jun;45(6):581–5.

    Article  PubMed  Google Scholar 

  38. 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 Feb;83(2):422–37.

    CAS  Google Scholar 

  39. 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. Journal of the American College of Cardiology. 1993 Aug;22(2):407–16.

    Article  PubMed  Google Scholar 

  40. Freemantle N, Cleland J, Young P, Mason J, Harrison J. beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ (Clinical Research) ed. 1999 Jun 26;318(7200):1730–7.

    CAS  Google Scholar 

  41. 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 Nov 5;366(9497):1622–32.

    Article  PubMed  CAS  Google Scholar 

  42. 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 Oct 21;260(15):2259–63.

    Article  PubMed  CAS  Google Scholar 

  43. 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. Journal of Interventional Cardiology. 2003 Aug;16(4):299–305.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Heart and Vascular Institute, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202, USA

    James McCord

Authors
  1. James McCord
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James McCord .

Editor information

Editors and Affiliations

    Rights and permissions

    Reprints and permissions

    Copyright information

    © 2009 Humana Press, a part of Springer Science+Business Media, LLC

    About this chapter

    Cite this chapter

    McCord, J. (2009). Medical Therapy in Patients Managed in a Chest Pain Observation Unit. In: Cannon, C., Peacock, W. (eds) Short Stay Management of Chest Pain. Contemporary Cardiology. Humana Press. https://doi.org/10.1007/978-1-60327-948-2_11

    Download citation

    • DOI: https://doi.org/10.1007/978-1-60327-948-2_11

    • Published:

    • Publisher Name: Humana Press

    • Print ISBN: 978-1-60327-947-5

    • Online ISBN: 978-1-60327-948-2

    • eBook Packages: MedicineMedicine (R0)

    Publish with us

    Policies and ethics

    Search

    Navigation