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CHAPTER 9 Chest pain and acute coronary syndromes
Joseph P. Ornato, Michael R. Sayre, and James I. Syrett
Introduction
In the United States, someone experiences a myocardial infarction every 26 seconds, and alarmingly, the disease claims one life each minute [1]. Heart disease accounts for twice as many deaths in the United States as are attributed to unintentional injuries, which has major implications for EMS systems [2]. About half of individuals who suffer acute myocardial infarctions (AMI) are transported to the hospital by EMS, and many more patients call EMS for help because they are experiencing chest pain [3].
The prehospital management of chest pain has improved with better clinical examination, earlier administration of effective medications, and the broad use of 12‐lead ECGs to detect acute coronary syndromes (ACS) and myocardial infarction more accurately before arrival in the emergency department (ED) [4]. Because more rapid reperfusion during acute myocardial infarction improves heart function and patient survival, EMS and health care systems have focused on developing strategies to identify chest pain patients with myocardial infarction quickly and to provide effective treatment while transporting them directly to definitive care [5–7].
The goals of management for patients with chest pain include rapid identification of the patient with ACS, relief of symptoms, and transport to an appropriate hospital. This chapter will cover the assessment and treatment of patients with the chief complaint of chest pain and will focus on the scientific basis for prehospital medical care of those patients. It will also review common conditions that can cause chest pain.
General approach
When evaluating a patient with a complaint of chest pain, EMS professionals should begin by assessing the patient’s stability and then obtain a basic clinical history and examination. Early in the assessment, an EMS clinician should apply a cardiac monitor to rapidly identify dysrhythmias, perform a diagnostic 12‐lead ECG, and administer specific treatment depending on the results of the initial evaluation. Because only a small minority of the patients with chest pain actually have ACS, maintaining vigilance in this assessment and diagnostic routine can be difficult [8].
Complete accuracy in the diagnosis of chest pain is not always possible in any setting, not even in the hospital [9]. The prehospital clinician should not expect to diagnose a patient with a complaint of chest pain definitively. A careful history can lead the clinician to a correct “category” of diagnosis much of the time. As a general approach, the patient should be treated as if he or she has the most likely serious illness consistent with the signs and symptoms.
Discomfort due to cardiac ischemia is usually, but not always, substernal and may radiate to the shoulder, either arm, both arms, upper abdomen, back, or jaw [9, 10]. Other symptoms such as nausea and diaphoresis are commonly present but do not accurately predict the presence or absence of ACS. Cardiac disease is most often seen beginning in middle‐aged men and older women. However, even younger adults under the age of 40 with chest pain but no cardiac risk factors and a normal ECG have a 1%–2% risk of ACS [11]. Taking a focused history using the “PQRST method” can be helpful (Box 9.1).
Box 9.1 Historical aspects of chest discomfort: the PQRST method
P:What provoked the pain or what was the patient doing when the pain started?
Q:What is the quality of the pain; burning, aching, squeezing, or stabbing?
R:Is there any radiation of the pain; does it go to the neck, jaw, arm, or back?
S:How severe is the pain? On a scale of 1 to 10, with 10 being the worst pain in one’s life, what is the pain now, and how has it changed?
T:What are the temporal aspects of the pain? How long has it been present? Has it occurred before? When?
There are many causes of chest pain, and their incidence changes depending on the characteristics of the population being studied. Patients calling on EMS are more likely to have acute myocardial infarction or other serious causes of chest pain than are patients in the general ED population [3]. Although the majority of this chapter focuses on the management of an ACS, other causes of chest pain are present more commonly.
Role of emergency medical dispatch
Prehospital care of
