Severe chest pain often spreading to shoulders, arms and neck which is caused by reduced blood flow to the heart with normal ECG or with reversible changes.
Medications:
Immediate therapy
- Tab. Myonit insta 0.5 (Nitroglycerin 0.5 mg) 1 tablet sublingually as soon as possible. Repeat dose after 5 minutes if needed and arrange transfer to hospital.
- Add tab. Ecosprin 75 (Aspirin 75 mg) 1 tablet once a day.
- Add tab. Nebi 2.5 (Nebivolol 2.5 mg) 1 tablet once a day. Increase this every three days till a maximum dose of 40 mg per day. Avoid combining it with non-dihydropyridine calcium channel blockers.
- Add tab. Timzid MR (Trimetazidine 35 mg) 1 tablet twice a day.
Resistant cases
- Add long acting nitroglycerin – tab. Nitrofix SR 30 (Isosorbide mononitrate 30 mg) 1 tablet once a day before breakfast. Gradually increase till a maximum dose of 240 mg. Contraindicated in myocardial infarction, marked anemia, head trauma, cerebral hemorrhage or closed angle glaucoma.
- If symptoms persist inspite of above combination, consider adding Tab. Cilaheart 5 (Cilnidipine 5 mg) 1 tablet once a day. Gradually increase till a maximum dose of 20 mg per day.
Investigations:
- ECG – to rule out ST-T changes, arrhythmias.
- Troponin I – if raised refer to cardiologist for further management.
- Lipid profile – to rule out hyperlipidaemia.
- HbA1c – to check diabetic control.
Referral:
Consider referring these patients for cardiology opinion or to a cardiac unit with catheter lab facilities.