2.2. CHEST PAIN/ACUTE CORONARY SYNDROME (ACS)/ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI)

Related terms

Heart attack, myocardial infarction (MI).

The purpose of providing EMS

1. Rapid diagnosis of ST-segment elevation myocardial infarction.
2. Determination of the time of symptom onset.
3. Preparation of the hospital system of medical care for ST-segment elevation MI.
4. Monitor vital signs and heart rate and be prepared to perform cardiopulmonary resuscitation (CPR) and defibrillation if necessary.
5. Use of necessary medications.
6. Transportation to the appropriate medical facility.

Patient description

Inclusion criteria

1. Chest pain or discomfort in other parts of the body (e.g., arm, jaw, epigastric region) caused by heart problems, shortness of breath, excessive sweating, nausea, vomiting, and dizziness. Atypical or unusual symptoms are more common in women, elderly patients, and patients with diabetes. Symptoms may also include signs of heart failure, loss of consciousness, and/or shock.
2. Some patients may have chest pain that is not caused by heart problems, meaning they are unlikely to develop ACS (e.g., blunt chest trauma in children). In these patients, postpone the administration of acetylsalicylic acid and nitrates according to the Pain Management guideline.

Exclusion criteria

None.

Provision of emergency medical services

Assessment, treatment and intervention

1. Signs and symptoms include chest pain, symptoms of heart failure, loss of consciousness, shock, symptoms similar to the patient’s previous MI.

2. Assess the patient’s heart rhythm – treat problems associated with rhythm disturbances, tachycardia, or bradycardia (see the Cardiovascular Problems and Resuscitation sections for guidance).

3. If the patient has shortness of breath, hypoxia or signs of heart failure, EMS workers should provide supplemental oxygen and maintain a saturation rate of 94-98% (see the General Rules of Care guideline).

4. A 12-lead ECG is the primary diagnostic tool for detecting ST-elevation MI. It is essential that EMS providers regularly obtain a 12-lead ECG within 10 minutes in all patients with signs and symptoms of ACS.

4.1 The ECG can be transmitted for remote interpretation by a physician or for screening for STEMI to appropriately trained EHR providers, with or without computer interpretation.

4.2. In the event of an MI, the hospital’s emergency department should be notified.

4.3. Periodic ECGs are desirable.

4.4. All ECG results should be available to physicians in the emergency department of the hospital where the patient is admitted or transported from the scene after hospitalization, and the ECG can be sent to the hospital during hospitalization, if possible.5. Надайте пацієнту ацетилсаліцилову кислоту; бажано без кишковорозчинної оболонки (доза від 162 до 325 мг).

6. Provide access to the computer.

7. Apply glyceryl trinitrate 0.4 mg sublingually, if necessary, repeat the procedure at intervals of 3-5 minutes, provided that the systolic blood pressure is above 100 mmHg (if the index (range) is lower, use an interval of 3 minutes).

7.1. Avoid the use of nitrates in patients who have used phosphodiesterase inhibitors within the last 48 hours.

7.2. Examples of such drugs are: sildenafil, vardenafil, tadalafil, which are used for erectile dysfunction and pulmonary hypertension. Also, avoid using nitrates in cases where patients are taking IV epoprostenol or trepostenol, which is used for pulmonary hypertension.

7.3. Use nitrates with great caution, if at all, in patients with posterior wall infarction or suspected right ventricular involvement, as these patients require adequate right ventricular (RV) preload.

8. Analgesia is recommended in ST-elevation MI and when chest discomfort does not respond to nitrates. Morphine should be used with caution in unstable angina (UA)/non-STEMI because of increased mortality.

9. The decision to transport should be based on available health care resources.

Patient safety

1. Examine the patient for signs of deterioration such as arrhythmia, chest pain, shortness of breath, altered level of consciousness/loss of consciousness, or other signs of shock/hypotension.
2. Perform a series of 12-lead ECG recordings (especially if there are changes in the patient’s clinical condition).

Useful information for training

Key points

Acute coronary syndrome may present with atypical pain, vague or generalized complaints.

Relevant assessment findings

A complete list of medications should be obtained. This is especially important for the physician in the emergency department, as he or she needs to know if the patient is taking beta-blockers, calcium channel blockers, clonidine, digoxin, anticoagulants, and medications for erectile dysfunction or pulmonary hypertension.

Key elements of documentation

1. Time of symptom onset.
2. Time from EMS contact with the patient to the moment of obtaining 12-lead ECG results.
3. Time of administration of acetylsalicylic acid or reason for non-administration.
4. Time of MI detection.

Criteria for the effectiveness of care

1. The time from the moment of contact with the patient to the acquisition of a 12-lead ECG should be no more than 10 minutes.
2. The time from the first 12-lead diagnostic ECG to the detection of ST-elevation MI.
3. Confirmation that the patient has received acetylsalicylic acid (taken before the arrival of the EMS, provided by EMS personnel, reasons for not using it).
4. The time of arrival of the patient with ST elevation MI to the hospital emergency department.
5. *Time from EMS notification to activation of the cardiac catheterization laboratory.
6. *Time from arrival at the percutaneous coronary intervention (PCI) center to cardiac catheterization (door to balloon catheter) or, if the patient is not transported directly to the PCI center, time between arrival at the hospital and receipt of thrombolytics.
7. *The time between the 12-lead ECG at the scene and the time of cardiac catheterization (time from ECG to balloon catheter).

*IMPORTANT: These measures can be assessed if the medical records can be combined with information received from the hospital’s admissions department.