Chest pain

Angina in older people may present with any of the following:

1. Typical angina symptoms (pressure-like chest pain / discomfort, central with radiation to jaw, neck, arm/ shoulder or upper abdomen, worse with exertion).
2. Shortness of breath.
3. Diaphoresis (sweating).
4. Nausea and vomiting.
5. Syncope or pre-syncope (dizziness).

Cardiac ischemia may also present with delirium or an unexplained fall.

Angina may be precipitated by underlying illnesses that stress the cardiac system - examples include underlying infection, dehydration, GI bleed or exacerbation of chronic disease.

If any of the following red flags are identified in residents who have chest pain, review the resident’s advance care plan, consult resident or substitute health decision maker (or nominated decision support person) and refer to Management of residents with unstable vital signs pathway.

The following are considered red flags in the resident with chest pain:

• Vital signs in the red or danger zone - refer to Recognition of the deteriorating resident
• Altered mental state or difficult to rouse relative to baseline
• The resident has ongoing severe chest pain despite appropriate management
• Syncope
• Chest pain associated with sudden onset of new neurological deficit
• Significant shortness of breath associated with chest pain
• ECG findings of new ST elevation or ST depression

Note: a decision to transfer a resident to hospital with chest pain should always consider resident goals of care and be respectful of informed choice by the resident (or substitute decision maker).

Goals of assessment of the resident with chest pain are to:

1. Identify the cause of chest pain.
2. Where the pain is consistent with cardiac ischemia, identify precipitants.
3. Identify complications of cardiac ischemia.

Identify the cause of chest pain -

• History from the resident and carers (and family where appropriate and relevant) for:
  • Nature and duration of pain
  • Radiation of pain
  • Associated symptoms
  • Prior episodes of the same pain and identified cause
• Examination including:
  • Vital signs
  • Focal chest findings such as focal crackles that do not clear with coughing
• Examples of assessment considerations are outlined in Table 1.
• Where a cardiac cause remains possible, perform an ECG and consider blood tests to assess haemoglobin, electrolytes, and troponin.

Click here for Table 1: Examples if considerations in assessment for acute chest pain.

Precipitants of cardiac chest pain include:

1. Acute coronary syndrome - suspect particularly if pain onset at rest or ongoing chest pain or acceleration of chest pain symptoms (unstable angina).
2. Exacerbations of chronic co-morbid conditions (e.g. Chronic Obstructive Pulmonary Disease [COPD]).
3. Development of an acute medical illness (e.g. sepsis, anaemia, arrhythmias, hypertensive urgencies, thyrotoxicosis).
4. Progression of valvular heart disease.
5. Medications that precipitate tachycardia (e.g. beta-2-agonists such as salbutamol, anticholinergic medications).

Identify complication of cardiac chest pain including:

1. Heart failure.
2. Cardiac arrhythmia or ischemia.

GTN is contraindicated if:

1. Systolic (top) blood pressure is < 110 mmHg.
2. Severe anaemia (haemoglobin less than 80).
3. Severe aortic stenosis or obstructive cardiomyopathy.
4. Sildenafil citrate (“Viagra”) or vardenafil administered in previous 24 hours or avanafil in previous 12 hours or tadalafil in prior 48 hours - note for all PDE5 inhibitors a longer interval is required if excretion is delayed due to drug interactions, renal or hepatic impairment - extreme caution is advised.
5. Known hypersensitivity to GTN.

Aspirin is contraindicated if:

1. Known hypersensitivity or allergy to aspirin or non-steroidal anti-inflammatory drugs.
2. Aspirin sensitive asthma.
3. Severe active bleeding.

Supportive care for residents with chest pain includes:

1. Avoid dehydration - where there is no clinical concern for heart failure, increase frequency of offering of fluids.
2. Falls risk management plan - residents who have had GTN are at increased risk for postural hypotension after GTN administration; ensure residents are sitting or lying when administering GTN and for a 5 minute period after GTN administration.
3. Manage contributors such as hypertension, anemia, infections etc.
4. Symptom relief - as determined by cause of chest pain. Where symptoms persist despite maximal therapy, consider consultation with the local HHS RaSS team at GP discretion.

First screen for red flags as above. Where there are no red flags, presence of any of the following may prompt escalation to HHS RaSS at GP discretion (or in resident’s nearing end of life, to the resident’s palliative care provider):

• Red flags in a resident who has conservative goals of care and does not wish to be transferred to hospital
• Resident has recurrent chest pain despite management
• Diagnostic uncertainty

1. Control risk factors including hypertension and blood glucose control in diabetes.
2. Consider pharmacological agents that may be of benefit in the individual resident.
3. Consider where appropriate, individualised graded exercise program guided by clinical status, symptoms, co-morbidities and frailty.
4. Identify and treat depression.
5. Manage contributors (e.g. anaemia).

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