Is pre-hospital treatment of chest pain optimal in acute coronary syndrome? The relief of both pain and anxiety is needed.
BACKGROUND
Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety.


OBJECTIVE
To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome.


METHODS
In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies.


RESULTS
Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease.


CONCLUSIONS
Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.
School of Health Sciences, PreHospen, University of Borås, The Pre-hospital Research Centre in Western Sweden, SE-501 90 Borås, Sweden; Inst of Medicine, Department of Metabolism and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden. Electronic address: johan.herlitz@gu.se.
Johan
J
Herlitz
School of Health Sciences, PreHospen, University of Borås, The Pre-hospital Research Centre in Western Sweden, SE-501 90 Borås, Sweden.
Angela
A
Bång
Inst of Medicine, Department of Metabolism and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
Elmir
E
Omerovic
School of Health Sciences, PreHospen, University of Borås, The Pre-hospital Research Centre in Western Sweden, SE-501 90 Borås, Sweden.
Birgitta
B
Wireklint-Sundström
D054058:Acute Coronary Syndrome / Q000150:complications / Q000523:psychology / Q000628:therapy*; D001007:Anxiety / Q000150:complications / Q000523:psychology / Q000628:therapy*; D002637:Chest Pain / Q000150:complications / Q000523:psychology / Q000628:therapy*; D004632:Emergency Medical Services / Q000379:methods*; D006801:Humans; D016896:Treatment Outcome