10% of Heart Attacks Go Untreated in EDs

10% of heart attacks go untreated: Don't let this happen in your ED

Emergency department nurses are 'critical link'

If a patient walked into your ED having a heart attack, could that patient be discharged without receiving life-saving interventions?

More than 10% of eligible heart attack patients may not receive potentially life-saving treatment in the ED, says a new study. 1 Researchers looked at 238,291 patients from the National Registry of Myocardial Infarction who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention (PCI), and they found that 11.6% were untreated.

"ED nurses may be the critical link between patients and appropriate care," says Brahmajee K. Nallamothu, MD, MPH, the study's lead author and assistant professor of internal medicine in the Division of Cardiology at University of Michigan Medical School in Ann Arbor.

This link is especially true for patients who come to the ED with subtle or atypical symptoms, according to Nallamothu. "I think three particularly important groups that ED nurses can make a large impact on are patients who present without classic chest pain, patients who present late after symptom onset, and those who drive themselves to the hospital," he says. For example, an elderly diabetic woman with no prior history of coronary artery disease who comes to the ED hours after symptom onset with shortness of breath, rather than angina, would probably get less attention up front by providers, says Nallamothu.

These heart attack patients are at high risk for not receiving treatment in the ED:

Patients with subtle or atypical symptoms.

Patients without chest pain or those whose electrocardiograms (ECGs) have fewer leads with ST-elevation were less likely to be treated in the study. "This may be because clinicians were unclear early on about the diagnosis," says Nallamothu.

Watch for subtle symptoms of heart attack, especially in women, says Lisa Medina, BSN, RN, program manager at St. John Heart Institute in Tulsa, OK. "If individuals present with any kind of pain between the naval and the jaw, heart attack should be considered," she says. "You particularly want to pay attention to middle-aged women who complain of shoulder pain and back pain."

A 40-year-old woman presenting to the ED with increasing fatigue over the past month and severe epigastric distress unrelieved by antacids may receive several diagnostic tests before an ECG is performed, says Medina. "With time of the essence in restoring myocardial perfusion, it is imperative to determine if symptoms are cardiac-related as soon as possible," she emphasizes.

Say the following at triage, advises Medina: Describe the pain or discomfort. What precipitated the pain? How is the pain relieved? Has the pain been experienced before?

Heart attack patients may report shortness of breath and nausea with no accompanying pain, says Medina. "Women often report pain or discomfort between the shoulder blades. Occasionally you get jaw pain with nothing else, and epigastric distress is fairly common," she says. "People may have self-treated with antacids prior to arrival."

Watch for nonverbal clues, such as a patient placing a closed fist to the chest or rubbing the chest in a generalized fashion, says Medina. "If someone can directly point to a place of pain and the pain is affected by moving an extremity or the chest wall, it may be musculoskeletal in origin," she says.

Emergency nurses at St. John obtain an ECG at triage for any patient complaining of chest pain or any of the above complaints, says Medina. "We try to err on the side of caution. We would rather obtain a normal ECG than miss an abnormal ECG," she says. (See steps taken for heart attack patients by ED nurses below.)