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Education/Training

STEMIs and Other Sources of Chest Pain

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Attack One responds to a morning call for a man having chest pain. The man is home alone and able to greet the crew at the front door. He is having chest pain and is short of breath.

He is 67 years old, with an extensive history of heart disease, and had some pain while doing his daily exercise routine. He quit exercising, but the pain did not stop. It is located in his left chest.

The paramedic leads the questioning: “What type of pain? Where else does it go? Is your heart skipping beats? Any nausea? Anything make it better? Have you taken any medicine for it?”

The patient gives rapid-fire answers until the last question. “My heart doctor says no nitroglycerin,” he tells the paramedic. “It may cause my heart to fail.”

With further history it is obvious this patient has extensive heart disease. He has had numerous “heart attacks” and multiple cardiac interventions, including the insertion of a pacemaker in his left chest. That area is where the pain is now occurring. The paramedic asks about other prior medical problems and any family history of cardiac disease. The patient has no medical problems other than his heart. “I’ve lived longer than any other male member of my family,” he reports proudly. “All the others died in their 40s or 50s from heart attacks.”

The EMT members of the crew place a pulse oximeter on the man’s right finger and check the blood pressure in his left arm. His oxygen saturation is in the high 90% range, and his pulse rate is regular. The 12-lead EKG pads are placed, and the paramedic examines the results.

“Sir, your EKG indicates you may be having another heart attack,” the medic says. “We will need to get you treated and transport you to the heart hospital that is nearby. We will not give you nitroglycerin, but will give you an aspirin and some medicine for your pain. I will call the hospital while my crewmates get you comfortable on our stretcher and into the ambulance.”

The patient doesn’t reply but has a puzzled look on his face. “Sir, this episode isn’t anything like my prior heart attacks,” he tells the paramedic. “The pain is sharp, and with every other attack I was soaking wet with sweat. Are you sure you’re reading that correctly?”

The paramedic understands the concern and makes firm eye contact with the patient. “Thank you for asking that good question; your history of having different pain with your heart attacks is very important. I will pass that information on to the emergency physician at the hospital, so they can make good decisions about how to set up for your care. Let me show you your EKG so you understand exactly what I’m seeing and what information I’m giving to the hospital.”

The medic reviews the 12-lead EKG printout with the patient; it reads Possible acute MI.

“Something isn’t right about this, but let’s go to the hospital to find out,” the patient responds. “You are taking me to my heart hospital, correct?”

He mentions a specific hospital where he’s had all his heart tests, interventions and pacemaker placement. It is located about 10 minutes farther away than the hospital to which the crew intended to head. The crew explains they’re headed to the other hospital, which has an active heart program and an interventional lab.

“With all respect to them and to you, I feel I will get better care if I go to my hospital,” the patient says. “You don’t understand how many heart problems they’ve pulled me through. I trust them fully. I’m having no pain now and really don’t think I’m having another MI. Please take me to my hospital.”

The paramedic looks at the three-lead cardiac monitor and pulse oximeter. Both show normal values, and the patient looks comfortable overall.

“Great information, sir. Let me talk to the ED there and make sure they are comfortable with us transporting you there. I will tell them the history, what the EKG shows and what you’ve requested.”

The hospital approves the decision and reports staff will be waiting for the patient, so the paramedic changes the destination. The patient receives aspirin and a dose of the pain medication fentanyl, and his discomfort decreases. The monitor shows ongoing sinus rhythm, and his blood pressure is stable.

Hospital Management

The ED is prepared for the patient’s arrival. The paramedic introduces the patient, hands the emergency physician the EKG and repeats the history. The physician asks if the crew will keep the patient on their stretcher and monitor. “We may need to have you take him up to the cardiac lab,” he notes.

In rapid succession, the ED nurses apply an armband, draw some tubes of blood for lab tests and perform a repeat 12-lead EKG. The patient record is called up on the computer, and the emergency physician says, “Sir, tell me again about your pain. Did you feel your heart ‘jump’ or a sharp pain in your middle chest, like you were kicked?”

“Sharp pain, right around the pacemaker area,” the patient replies. “Nothing like my prior heart attacks. No kicks in my chest.”

“I have really good news for you,” the doctor says. “The EKG done in your home, the EKG we just did here and the last EKG we have in your record from about a month ago all look the same. And I see in your record that you have an abnormality of your heart called a ventricular aneurysm, which is why they placed a pacemaker and a defibrillator. Your heart doctor was concerned you had a very low heart rate and that your heart may start beating in an irregular fashion. We will have to see if your heart has suffered any event through some blood tests. We will use a device to ask the computer in your chest if it’s found any rhythm problems. All that information will be sent to your heart doctor, and we will help you decide what needs to happen next.”

The patient does well through a short period of observation in the ED. He has blood work that shows no heart damage, and his pacemaker and defibrillator show no abnormalities of his heart rhythm. On examination by the emergency physician and his cardiologist, it appears the pain is from irritation around the heart device in his chest wall. He is released to go home and given instructions and a copy of his old EKG to keep with him.

“Sir, the changes in your heart from your prior MIs have left a permanent change in your EKG that looks like a fresh heart attack,” the doctor tells him. “When you call EMS or go to an emergency department in the future, you’ll need to need to let them know you have a ventricular aneurysm and changes in your EKG that are the same as those that occur with an MI. Please let them see the copy of your EKG that we have given to you.”

“An old EKG to carry with me—what a great idea,” the patient responds. “I’ll never leave home without it!”

A 67-year-old male in mild distress complaining of chest pain. He has an extensive history of heart disease.

Initial Assessment

Airway: Intact.

Breathing: Breathing normally; lungs clear on auscultation.

Circulation: Regular pulse rate and quality. Normal capillary refill, pink skin. Neck veins mildly distended, good peripheral pulses.

Disability: No neurologic deficits.

Exposure of Other Major Problems: No trauma. Heart device placed in left chest wall.

Vital Signs

Time              HR                  BP                      RR                    Pulse Ox.

1050              73               184/84                   28                         95%

1057              72               180/76                   24                         97%

1104              72               174/80                   24                         98%

AMPLE Assessment

Allergies: None.

Medications: Extensive list of cardiac medicines. He is on a new form of blood thinner, plus several blood pressure medicines.

Past Medical History: Extensive history of cardiac problems and procedures, including placement of a pacemaker. Family history of coronary artery disease in multiple relatives.

Last Intake: Breakfast about four hours prior.

Event: Patient developed pain and shortness of breath doing exercise in his home.

Case Discussion

There are many causes of chest pain and many reasons why abnormal EKGs may be present. This case demonstrates the presentation of a patient who has risk factors for an acute ST-segment elevation myocardial infarction (STEMI). The occlusion of coronary arteries needs to be addressed quickly, and most communities now have systems that allow activation of interventional teams at hospitals prepared for such patients.

Most communities use criteria based on the initial 12-lead EKG to activate their “cardiac alert” systems. But EMS personnel need to be aware that not all 12-lead EKGs indicating possible acute MI are in fact that disease. In many cases there are alternative causes for that EKG finding.

This patient had a ventricular aneurysm, which is a weakening and bulging of the wall of the heart, usually caused by an acute MI. The abnormal movement of the wall changes the electrical activity in the EKG, giving the appearance of elevated ST segments. The location of those elevations depends on the area of the heart that is damaged.

The finding of elevated EKG segments can occur in patients having strokes; those having certain electrical problems in the heart, like a bundle branch block; in patients who have very elevated potassium levels; in patients with inflammation of the lining of the heart, called pericarditis; in those with prior damage to the heart, like this patient; and with some other, less common diseases. Some patients will give a history of having an abnormal EKG, and in such cases EMS personnel must rely on the patient’s history and symptoms to develop appropriate treatment and transportation plans. It can also be very hard to time the therapy for STEMIs in these patients because of the uncertainty of the cause of the EKG abnormality.

There are advanced lessons in EKG interpretation that will allow some causes of ST elevations to be determined. Many involve the use of old EKGs to provide a comparison, as in this patient. In some cases, EMS transportation to the hospital where old EKGs are present, and where prior cardiac interventions have been performed, will have significant patient benefit. This patient was taken to a hospital that had an interventional cardiac lab and where he’d received prior care.

In some cases, additional testing must be done in the ED to determine if the patient is suffering from an acute occlusion of blood flow to heart muscle. This may involve blood testing, an echocardiogram or a trip to the interventional lab for diagnostic testing.

Customer Service Opportunity

The patient with heart disease will often have significant knowledge of their underlying heart or blood vessel problem. In some cases they will be carrying information about their disease, including old medical records, copies of old EKGs and other important test results. EMS personnel may not understand all the detail in those reports, but it is important that EMTs carry that information to the hospital with the patient. In a few cases, portions of the information can be communicated to medical control personnel when a patient report is given.

In addition, using those documents as a source of information may facilitate communication with the patient. Since patients with heart disease may have a high degree of anxiety, use of terminology contained in the medical records may be comforting. For example, the report to the hospital may be something like, “This patient feels his symptoms are similar to his last episode of chest pain a month ago, and according to the records he has with him, his heart catheterization at that time indicated he had good heart function and no significant blockages.”

This high level of professional communication and honest information may gain significant trust. It also provides critical patient information to the receiving hospital. Furthermore, EMS providers will help many patients by portraying and delivering a confident message regarding the decision to transport to a certain hospital.

Learning Point

Many patients now live with extensive levels of heart disease. Some will have complex and confusing clinical symptoms that represent their form of heart problems. Transportation protocols must recognize the special needs of certain groups of patients, including those with extensive medical histories and interventions that have taken place at specialty centers. It is particularly important in patients with heart disease that a careful history is obtained regarding prior diagnoses, tests and symptoms expected to occur.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.

 

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