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Posted: November 28th, 2022
A 55-year-old male who had been experiencing chest pain for eight hours recently visited the office, according to my recent clinical experience. His right arm was also being affected by his crushing, excruciating chest agony. Additionally, the patient seemed pale and was diaphoretic. His 12-lead first EKG revealed a heart rate of 102, a first-degree AV block, sinus rhythm, low voltage QRS, and an active anterior wall infarct. Although more than 30% of patients with NSTE-ACS may have normal ECGs, common abnormalities include ST-segment depression, transient ST-segment elevation, and T-wave changes.
Vital values for the patient were 180/97, 95, and O2 92%. His pulmonary examination revealed no changes. He was a smoker and had a history of smoking-related hypertension and hyperlipidemia. According to hospital records, aspirin was administered at the office, and the paramedics administered 5 mg of metoprolol while transporting the patient to the hospital.
The patient was hesitant to go to the emergency room when he scheduled a primary care appointment over the phone, so we repeatedly warned him about the consequences of his choice. He merely desired to be observed at the office. After all, we did the interventions we could do in the office until he ultimately agreed to go to the Emergency room.
Although it is not frequently seen in primary care, chest discomfort does happen occasionally. As a result, clinicians need to be aware of potential red flags, know when to send patients to emergency medical services, and have low referral thresholds. According to a study by Andersson et al. (2018), 94% of 688 MI patients who contacted primary care rather than the advised EMS experienced the cardinal symptoms of an acute MI, which include chest pain, radiating pain to the arms, and/or cold sweat. These patients had a mean age of 66 years and were made up of 519 men and 169 women.
To make a diagnosis or determine the need for the patient to be seen by EMS, primary care providers must rely primarily on history taking, physical exams, and previous experiences. Less common but urgent diagnoses of chest pain, such as acute coronary syndrome or pulmonary embolism, are distinguished from more common but less urgent diagnoses (such as gastroesophageal reflux, musculoskeletal pain, or anxiety).
At this patient’s hospital follow-up visit, chronic care management could include a variety of interventions. Heart failure (HF) management and education, labs to assess kidney function while on Lisinopril, and medication management are a few examples. The patient may also require a referral to a cardiologist or a nutritionist to discuss heart-healthy diets. He may also need to be on cardiac drugs for the rest of his life, which will necessitate ongoing lab tests to assess the metabolic functioning of other organs, such as the kidneys. The patient may also require ongoing discussions about smoking cessation as well as encouragement to quit. Overall, the medical care provided at the hospital, the hospital discharge report, and the patient’s needs will all contribute to determining what he requires for chronic care management.
References
P. O. Andersson, S. S. Lawesson, J. E. Karlsson, S. Nilsson, I. Thylén, and the SymTime Study Group A cross-sectional study of patients with acute myocardial infarction who contact primary care before hospitalization. 19(1), 167. BMC family practice. https://doi.org/10.1186/s12875-018-0849-8
Collet, J. P., Thiele, H., Barbato, E., Barthélémy, O., Bauersachs, J., Bhatt, D. L., Dendale, P., Dorobantu, M., Edvardsen, T., Folliguet, T., Gale, C. P., Gilard, M., Jobs, A., Jüni, P., Lambrinou, E., Lewis, B. S., Mehilli, J., Meliga, E., Merkely, B., Mueller, C., … ESC Scientific Document Group (2021). Guidelines from the European Society of Cardiology (ESC) for the management of acute coronary syndromes in patients who do not have persistent ST-segment elevation. 1289-1367 in European Heart Journal, 42(14). https://doi.org/10.1093/eurheartj/ehaa575
Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. e027081 in BMJ Open. https://doi.org/10.1136/bmjopen-2018-027081
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