Same clot, different artery

The same blood clot that could have caused a stroke could land in a coronary artery, resulting in decreased blood flow through the myocardium. The more blood flow is cut off from the obstruction, the more it hurts. To make matters worse, the blood vessels could be narrowing due to a build up a substance called plaque. Plaque is comprised of calcium and cholesterol and binds to the walls of arteries, eventually making them narrower, and the condition worse. A buildup of plaque could eventually lead a patient to have atherosclerosis and arteriosclerosis. Atherosclerosis is the thickening and hardening of arteries. Arteriosclerosis is the narrowing of arteries. Angina is a condition where there is a chronic decrease in blood flow to the myocardium, usually due to arteriosclerosis and atherosclerosis. Blood clots floating around the body can occlude the coronary arteries causing the patient to experience myocardial ischemia (hypoxia in myocardial cells) or myocardial infarction (cell death).

It’s impossible to tell the difference between angina and acute coronary syndrome

What are the medics to do when confronted with the possibility of a fairly benign and self relieving condition (nitrates and rest is usually all it takes to reverse angina) and the potentially life threatening condition of acute coronary syndrome (lethal in that acute coronary syndrome can lead to sudden cardiac arrest) kind of look the same? The medics should assume that the condition they are faced with is the worst condition for the patient. In other words, assume the worst. If the patient is complaining of chest pain, EMS has no other recourse but to assume the patient is suffering from a myocardial infarction.

Assessment

The patient complains of chest discomfort or pain. Sometimes the patient describes the pain as a pressure sensation, sometimes making it more difficult to breathe. Being able to ask and document the patient’s complaint is a skill that all medics should possess:

• Onset – “Did the chest pain increase to where it is now, or did it get worse since the chest pain started?”
• Provocation – “What makes it worse (or better)?”
• Quality – “How would you describe the chest pain?”
• Severity – “On a scale of 1 to 10, how would you rate the pain?“
• Time – “When did the chest pain start?“

In addition to chest pain, the patient may also experience nausea and vomiting and diaphoresis (profuse sweating).

The patient is likely to have a history of predisposing factors to acute coronary syndrome

• Hypertension
• High cholesterol
• Diabetes
• Previous history of acute coronary syndrome

Sometimes the patient has already been prescribed medications for chest pain. Nitroglycerin is commonly prescribed for chest pain. If the patient’s blood pressure is above 130/mm Hg systolic, the patient may be able to self treat their chest pain with their own nitroglycerin. Many patients are prescribed aspirin. Aspirin prevents blood clots from getting bigger and is considered a prophylactic measure often recommended on patients with the risk factors mentioned earlier.

Vital Signs

The average chest pain patient will be hypertensive (systolic blood pressure greater than 140/90). Sometimes patient’s with chest pain also experience shortness of breath as demonstrated by a respiratory rate greater than 20. Sometimes patient with chest pain experience dyspnea on exertion (shortness of breath when performing physical activity). Patient’s with demonstrated shortness of breath require oxygen therapy. The patient may have an irregular or rapid pulse. Each finding means something and should be communicated accurately in speech and writing.