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Figure 3 Patient (Advance) Instructions for NTG Use and EMS Contact in the Setting of Non–Trauma-Related Chest Discomfort/Pain

If patients experience chest discomfort/pain and have been previously prescribed NTG and have it available (right side of algorithm), it is recommended that they be instructed (in advance) to take 1 dose of NTG immediately in response to symptoms. If chest discomfort/pain is unimproved or worsening 5 min after taking 1 NTG sublingually, it is recommended that the patient call 9-1-1 immediately to access EMS. In patients with chronic stable angina, if the symptoms are significantly improved after taking 1 NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 minutes for a maximum of 3 doses and call 9-1-1 if symptoms have not totally resolved. If patients are not previously prescribed NTG (left side of algorithm), it is recommended that they call 9-1-1 if chest discomfort/pain is unimproved or worsening 5 min after it starts. If the symptoms subside within 5 min of when they began, patients should notify their physician of the episode. (For those patients with new-onset chest discomfort who have not been prescribed NTG, it is appropriate to discourage them from seeking someone else’s NTG [e.g., from a neighbor, friend, or relative].) *Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. EMS = emergency medical services; NTG = nitroglycerin.