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n Summary and recommendations
First line:
n nitrates: SL nitroglycerin (0.4 mg SL every 5 min); for continuing pain after
three doses of SL nitroglycerin: IV nitroglycerin infusion (begin infusion at
5 μg/min and titrate to pain and blood pressure, maximum dose usually
100 μg/min but up to 200 μg/min sometimes used)
n beta-blockers: metoprolol (5 mg IV every 5 min to 15 mg total; follow with PO
load of 50 mg 15 min after last IV dose); other beta-blockers may also be used
n oxygen: administer oxygen to maintain SpO2 at least 95%
n opioids: morphine (initial dose 4–6 mg IV, then titrate); other opioids may
also be used
Pregnancy: importance of maternal analgesia (and associated salutary effects
on outcome) outweighs fetal concerns; ACS pain therapy in pregnancy is
thus unchanged from that in other situations
Pediatric: children with ACS will probably be suffering from congenital
anomalies or metabolic syndromes; therefore, pain management is best
coordinated with subspecialists; fentanyl (initial dose 1–2 μg/kg IV, then
titrate) may be preferred owing to its minimal hemodynamic effects
Special cases:
n cocaine-associated chest pain: avoid beta-blockers (including mixed alphaand
beta-blockers) and instead use benzodiazepines (e.g. lorazepam 1 mg
IV with repeat doses as needed)
n hemodynamic concerns: Use fentanyl (initial dose 1–2 μg/kg IV, then titrate)
References
Cardiac chest pain 165
1. Nicholson C. A systematic review of the effectiveness of oxygen in reducing
acute myocardial ischaemia. J Clin Nurs. 2004;13(8):996–1007.
2. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guidelines for the
management of patients with unstable angina and non-ST-segment elevation
myocardial infarction: executive summary and recommendations. A report of
the American College of Cardiology/American Heart Association Task Force on