Coronary Artery Disease

EMT

Introduction

Coronary artery disease (CAD) results in restricted blood supply to the heart, usually though narrowing of the coronary
arteries.

CAD is the most common type of heart disease, which is the leading cause of death in the United States.

CAD is the underlying background that leads to myocardial infarctions (heart attacks) and other causes of ischemic chest
pain.

Lessons and Concepts

The myocardium (heart muscle) is supplied by its own network of blood vessels, as the heart wall is
too thick to receive oxygen and nutrients directly from the ventricles.

Anytime these coronary vessels fail to meet the demand of the heart muscle, a patient may experience ischemic chest
discomfort.

This can manifest as chest pain, shortness of breath, nausea, dizziness, weakness, or a number of other symptoms.

The root cause of CAD is usually a process called atherosclerosis.

Atherosclerosis is a process of fatty plaque buildup within the lining of a blood vessel that restricts blood flow through
the vessel.

Stenosis refers to narrowing of the blood vessel.

If a plaque ruptures, this can lead to rapid blood clot (thrombus) formation.

This blood clot restricts blood flow to the myocardium (heart muscle).

The result is an infarction, referring to tissue death caused by ischemia.

Important terms to remember:

 Ischemia refers to an inadequate blood supply to a tissue.

Angina or angina pectoris refers to chest pain caused by ischemia.

Myocardial infarction refers to death of heart tissue as a result of inadequate tissue perfusion. Myocardial infarctions
are often referred to as heart attacks.

Myocardium is the muscle layer of heart tissue.

Thrombus is a blood clot. These occur in blood vessels when a fatty plaque ruptures and activates clotting factors.

Atherosclerosis is a process of fatty plaque buildup within the lining of a blood vessel that restricts blood flow through
the vessel.

Coronary arteries are blood vessels on the heart's surface that deliver oxygen and nutrients to the heart.

Recognition

The hallmark symptom of CAD is chest pain.

This may radiate to the arms, neck, jaw, back or abdomen.

Usually worsens on exertion.

Certain populations are more likely to experience an atypical presentation.

These populations include females, diabetics, and elderly patients.

The chief complaint may be nausea, anxiety, shortness of breath, or another symptom.

May be associated with other signs and symptoms of heart failure.

Left-sided heart failure can result in respiratory distress with cariogenic pulmonary edema (wet lungs).

Right-sided heart failure can result in swelling of extremities, pitting edema, and jugular vein distention (JVD).

Look for pale or diaphoretic (sweaty) skin as indications of impaired circulation.

Chest pain patients can usually be put into one of two main categories:
 Stable ischemic heart disease leads to ischemic chest discomfort during periods of increased exertion or stress.

Stable angina refers to chest pain that is relieved by rest or nitroglycerin.

Acute coronary syndrome (ACS) comes with chest pain (usually sudden onset) that is not relieved by rest and is not
stable. There are three sub-categories:

Unstable angina refers to chest pain at rest.

NSTEMI or NSTE-ACS is one type of heart attack.

STEMI is a serious heart attack that can be diagnosed on an ECG.

Treatment and Management

Initial management begins with addressing any immediate life threats and managing any problems that compromise
airway, breathing, or circulation.

Consider the need for oxygen and positive pressure ventilatory support.

Position patient to support breathing and/or circulation.

Obtain baseline vital signs.

Obtain a 12-lead ECG as soon as possible.

Even though an EMT is not trained to interpret ECGs, an EMT may obtain one so that it is available to a trained provider.

In many EMS systems, you may transmit an ECG to the receiving hospital.

Always obtain an ECG for pain or any complaint above the umbilicus (belly button).

Obtain patient history and perform detailed patient assessment.

Visualize and palpate the chest.

Listen to lung sounds.

 Screen for cardiac and/or respiratory history.

At the EMT level, treatments for chest pain include:

Supplemental oxygen to maintain 90% saturation or higher (or per protocol).

American Heart Association (AHA) recommends titrating to 90%.

Unnecessary oxygen can restrict coronary blood flow.

162-325mg of aspirin (usually 2 or 4 81mg chewable baby aspirin).

Goal is to slow the formation of blood clots (anti-platelet).

Aspirin is also an NSAID (pain reliever) but not given for this purpose.

Patients are often instructed to take aspirin by 911 operator.

Contraindications include allergy and active GI bleeding.

Assist patient to self-administer their own prescribed nitroglycerin (usually 0.4mg sublingual tablets).

Nitroglycerin is a vasodilator that can reduce workload on the heart and increase blood flow to the myocardium.

Contraindications include hypotension, bradycardia, and concurrent medications for erectile dysfunction (within 24-48
hours).

Transport to an appropriate facility per local protocol.

Chest pain patients should generally be taken to larger, more capable hospitals.
Scenario

You and your EMT partner are dispatched to the home of a 74-year-old female complaining of chest pain, shortness of
breath, and nausea. An ALS ambulance is also en route but is further away. You arrive to the well-kept home of an elderly
couple and find the patient seated in a recliner. The patient appears diaphoretic (sweaty) and appears to be breathing
heavily.
You direct your partner to obtain baseline vital signs while you begin your primary assessment.
Airway: The patient appears to be breathing spontaneously through a patent airway.
Breathing: You note rapid breathing and immediately listen for lung sounds. You hear clear lung sounds throughout. The
patient is breathing at a rate of 34/minute and has an initial spO2 of 94%.
Circulation: You feel for a radial pulse and assess skin color. You also check for peripheral swelling and jugular vein
distention (JVD). You feel a strong radial pulse with pink, warm and diaphoretic skin. You do not note any peripheral
swelling or JVD.
Your partner reports baseline vitals as follows:

BP 98/42

HR 94 and regular

SpO2 of 94%

You direct your partner to obtain a 12-lead ECG while you move on to your secondary assessment. You obtain a full
SAMPLE history. The patient reports a history of high blood pressure that is managed with medication. She denies any
other medical history.
You prepare to administer initial treatments for chest pain. After confirming the patient has not already taken aspirin and
confirming they have no allergies and no active GI bleeding, you administer 324 mg. of aspirin. The patient does not have
a prescription for NTG to assist with. You elect to withhold oxygen per your protocol because the patient is not hypoxemic.
While awaiting ALS transport, you carefully monitor your patient for any changes and obtain repeat vitals signs every 5
minutes with no changes.
On arrival of ALS, you provide a thorough verbal report to the responding paramedic and provide a 12-lead ECG. The
paramedic determines that the patient is having a STEMI (type of heart attack) and places defibrillator pads on the patient
preemptively. They request you ride with the patient to the hospital as an extra crew member. During emergency
transport, the paramedic obtains IV access and administers 3 doses of nitroglycerin. Care is transferred to a hospital that
urgently takes the patient for stent placement. The patient makes a full recovery with no lasting damage to their heart.
Key takeaways: Initial treatment and management significantly speeds up the patients ultimate arrival at definitive
care. Obtaining an ECG is crucial even if you are unable to interpret it. Remember to perform a detailed assessment
before administering treatments. The only exception is a threat to airway, breathing, or circulation (e.g. oxygen when
necessary).

Tips and Tricks

 Always remember to focus on the ABCs.

Drugs and treatments come after a primary assessment.

If something compromises the airway or breathing, treat it.

Remember to ask about drug allergies and drug contraindications.

For example, always ask about active GI bleeding prior to giving aspirin.

Always obtain an ECG.

References

1. Shahjehan RD and Bhutta BS. 2021. Coronary Artery Disease. StatPearls. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK564304/

2. Coronary Artery Disease: Overview. 2017. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK355313/

3. Coronary Artery Disease (CAD). 2019. Centers for Disease Control and Prevention. Retrieved from
https://www.cdc.gov/heartdisease/coronary_ad.htm

4. National Model EMS Clinical Guidelines. 2019. NASEMSO. Retrieved from https://nasemso.org/wp-
content/uploads/National-Model-EMS-Clinical-Guidelines-2017-PDF-Version-2.2.pdf

5. Advanced Cardiovascular Life Support. 2020. American Heart Association.