# Angina Pectoris vs Myocardial Infarction



## Sugi (Oct 23, 2009)

So Im a new EMT, just got my Arizona license a few days ago, and I got into a sort of discussion with my uncle, who was an EMT-i years ago (1980's). We got to talking about Angina Pectoris vs Myocardial Infaction's and I was wondering, is there a way to tell the difference?


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## Melclin (Oct 23, 2009)

I'm not having a go at you..but is that not taught in the EMT course? Golly.

An infarction is localised cell death caused by an occlusion of the blood supply to that area. It can be caused by a number of things and happen in many places throughout the body, though some are more prone than others. Its most infamous manifestation is the Acute Myocardial Infarction. 

Angina pectoris is descriptive of a set of symptoms (central, retrosternal pain, tightness, SOB ) that form a syndrome, not a particular disease process and it can be caused by a number of things, most common of which is narrowing or the arteries because of atherosclerotic plaque.


The typical AMI has it's origins early in life. Some have even suggested that plaque begins to form on the artery's walls in the womb, but it any case, it starts young. The details of its birth and formation you can read for yourself in any good pathophys textbook, but in short a plaque is a thrombogenic lipid rich interior encased in a more robust collagen cap. As plaques expand into the lumen of the artery, they take up space where blood is supposed to be flowing. This happens concurrently, all over the body, but the heart and brain are the most susceptible to reduced blood flow. The narrowing means that the heart gets less blood, which means less O2 (at the same time because of the narrowing/hardening or arteries, it has to use more O2, to work harder to get blood around the body, so its a double whammy). Often a person in the later stages of this disease may experience pain on exertion, which then dissipates when they rest. This is because while exercising, the heart needs more O2...O2 which it cannot get, so it 'screams' in pain/tightness/discomfort. But when the person rests, so can the heart and so it requires less O2. Now that the heart is less demanding, the O2 supply its getting through the narrowed arteries is just enough again, so the pain goes away. This is stable angina, or angina pectoris.

Now in a case where one of these plaques burst and the thrombogenic interior is exposed to the blood stream, it does just that...it generates thrombi, which block the supply of blood. There are a number of ways in which this happen, but in a general sense, the vast majority of infarcts are caused by complete (or near enough) blockages like this. It is relatively sudden and complete, so the areas that can't get O2, failing some fine diagnosis and expeditious treatment, will die. This is an AMI.   

The world is never so simple though; UA/nSTEMIs can provide a world of confusion to you if you are simply trying to break things down to angina and infarct, but that can come later.

With any chest pain, you should be asking the pt (amongst other things) about when the pain came on, what they were doing when it did and if anything made the pain better/was it constant. 

The picture of angina is typically someone who experiences chest pain and excessive SOB while they were doing exercise, but when they sat down it went away. Angina is also more responsive to treatments like nitro and O2. It also tends not last for two long. Some say 5 mins, some say 10, the AHA says a maximum of 20; but put it this way, if a person has had the same crushing chest pain for an hour now....its not stable angina/angina pectoris.

Unstable angina and MIs on the other hand can come on at rest (although they can come on anytime) and tend not to improve when they sit down and take a breather. They tend not to be as responsive to treatment, sometimes not at all. The pain remains in intensity or may get worse. Often pt will have a history of angina that has been getting worse lately; this is a big warning sign and one of the criteria for upgrading a diagnosis of stable angina/angina pectoris, to unstable angina, which, if you are only having two buckets, goes in the 'heart attack' bucket rather than the 'plain old angina' bucket. 

I'm told few people ever conform to the classic picture of a heart attack, but those rules above should do you well in general.  

Some reading...

Angina Pectoris
http://www.merck.com/mmpe/sec07/ch073/ch073b.html

AMI
http://www.merck.com/mmpe/sec07/ch073/ch073c.html


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## daedalus (Oct 23, 2009)

Hi Melcin,

No, the differences between angina and MI are not taught to United States EMT students. Sad, huh?

OP, Melcin gave you a good run down. Your job as an EMT is to treat all chest pain as serious. However, recognize that this is a "continuum" of sorts that chest pain of cardiac origin can be classified as. It goes from stable angina (relieved with rest/nitro at home) all the way to MI (death of heart tissue). In between there is Unstable Angina which requires cardiologist consultation at the hospital before discharge. In addition, the nomenclature for MI now includes "NSTEMI" and "STEMI". STEMI is usually caused by a complete occlusion of a coronary artery that supplies the heart tissue, and is identified because of characteristic changes on the EKG (elevation of the "ST" segment of the tracing in leads where the MI is occurring). NSTEMI may not be immediately identified on the EKG, but may be diagnosed after blood work has come back in the ER. 

If you can get your hands on a paramedic textbook, it has a more detailed breakdown of what Melcin wrote above, and if you are really interested try reading the cardiology chapter in an Internal Medicine book at Borders or Barnes and Noble (something like Harrison's Internal Medicine).


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## MIkePrekopa (Oct 23, 2009)

In my EMT-B class we were taught the difference, but we were also taught that we aren't to diagnose, just treat the symptoms and get them to the hospital asap. We were told that the pain of an MCI is much much worse, and has a tendency to stay for a lot longer than angina. also that typically, though not always, angina goes away, or feels a little better with rest where a MCI doesn't.


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## Shishkabob (Oct 23, 2009)

The main difference you need to know, in simple terms, is angina is pain brought on by insufficient oxygen supplied to the heart to meet it's needs, while infarction is the actual death of the cells if they go without oxygen for long enough.  


Ischemic and injured cells (from "best" to moderate) can both be re-oxygenated with very little, if any, long term damage.  Once a cell reaches the infarct stage, it's gone for good.




Now, something to keep in mind, just because there is ST-elevation does NOT mean there is an infarct happening, as there is a condition called Prinzmetals angina, which causes ST-elevation which can disappear as soon as nitro is administered, which is why medics love to have 12-leads done BEFORE nitro / morphine is administered as that is really the only way to diagnose Prinzmetals.  If left untreated, there is a, I believe, 75% chance an MI will occur in the next 6 months.


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## Sugi (Oct 24, 2009)

It isnt so much that I wasnt taught the difference in class, but I wasnt exactly told how to tell the difference in the field. 

Thought MIkePrekopa brings up a good point. Not my job to diagnose, just my job to get them to a hospital.

Thanks for the info guys


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## JPINFV (Oct 24, 2009)

Sugi said:


> It isnt so much that I wasnt taught the difference in class, but I wasnt exactly told how to tell the difference in the field.


The problem is that, as a basic, you don't have the tools necessary to rule either way. 


> Thought MIkePrekopa brings up a good point. Not my job to diagnose, just my job to get them to a hospital.



In my opinion, that is completely opposite way from how you should look at providing *medical care.* Now, yes, the training and education for EMT-Bs is limited. Yes, as such the diagnostic tools and treatment interventions are limited. However, you should always strive to develop a differential diagnosis or a field diagnosis for the patient. I say this for a few reasons. 

One, there are signs and symptoms that have different treatments. 

Two, if you start studying what different conditions are, you can catch more. All of a sudden patient A isn't really an emergency because, despite how critical the patient might look on the outside, X explains everything and is likely. Now there isn't a reason to go screaming down the road lights and sirens. On the opposite end, patient Y looks fine, but your history and physical assessment keys you to problem Z, which you know is a medical emergency and take appropriate steps.

Three. It's always good to be able to defend your treatment plans. In my time working, I think I pulled the "but but but protocol" card an entire one time and felt rather dirty afterwords. Treat the patient, not the protocol, however your treatment plan should match up with the protocol fairly well. 

Four, when you become a paramedic or any other higher level provider, the expanded diagnostic tools and treatment interventions makes coming to a logical and educated conclusion vital to your success as a medical provider. It's best not to fall into the hole of "ho, hum, we only treat signs and symptoms and read off a protocol" now than to try and break it later.


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## MrBrown (Oct 24, 2009)

A timely reminder to remember for those of us who can it's important to record cardiac rhythm before giving GTN, aspirin or oxygen.

The 30 seconds it will take to get an ECG means you have the basis for serial evaluation and trend analysis.  So if your do have T wave changes which subsequently vanish post treatment there is still evidence that they were there.

Very handy to show the ED staff for proper triage.


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## Sugi (Oct 24, 2009)

wow its really been interesting getting a different perspective on things. To be honest, all 11 of my instructors all have roughly the same perspective... So there was not much room for debate there.

But really, I understand the perspective of "im not trained to diagnose, so just transport" but it also makes sense from a triage standpoint, and from just a basic care standpoint to try to make a diagnosis...


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## MIkePrekopa (Oct 24, 2009)

I do agree with what JPINFV said, but for _me, right now_, its "memorize the book so I can pass the test". I don't like the idea of _just_ treating the symptoms and give 'em high flow diesel (in proper dosage) to definitive care, but thats what I'm to memorize for now. After I finish class, I can learn anything and everything I want, but right now I'm working on learning just what the book wants me to do. The way one of my instructors put it to me is "you go to school to learn the rules, you work in the field to see which you need to follow." Not that rules are to be broken, but does EVERY one of your patients get 15L O2 via non rebreather? We get to learn proper dosing of activated charcoal even though local protocols took it off the ambulances a few months ago. 

I understand why they don't want us to diagnose in the field. With limited contact, and fewer resources than an EMT-P or hospital staff, an EMT-B is less likely to come to a correct diagnosis, and if we diagnose incorrectly, and subsequently treat incorrectly, we can do more damage than good. But at the same time learning never hurt anyone.

I suppose in my ramblings at 0500 I'm trying to say its good to be able to diagnose what your dealing with, but at the same time you need to remember local protocols. If you begin treating causes and not symptoms something will go wrong. You can learn outside your job, but in doing so, be sure your doing YOUR job properly. Don't let something you read in a EMT-P book bias you to do something beyond what your allowed. 

</0500 ramblings>

Have a good night....... erm... day everyone... :blink:


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## Melclin (Oct 24, 2009)

PLUS ONE TO JPINFV

Sugi,

TONED OUT : 3:23PM  47 Female - Trauma; Extremity.

You're pt's foot really hurts. BLS job right? Nothing to worry about? Why does education make a difference?

She a bit pale when you get there and she's got new pit stains. Her face is dry but you notice a hankerchief in her hand. With some further questioning, she turns out to be a diabetic. Her BP is 130/90 thats within the limits of normal for the Idiot's guide to  EMT-Basic book right? Still a BLS job? 

This is a real case by the way. Luckily the basic here have a much better education and some good tools. Luckily they saw this for what it was and had ALS back up role L/S which was a good thing too because she arrested halfway to an appropriate PCI hospital. She lived (ALS got her back and rolled straight into the cath lab because we're cool like that B) ), but you have to wonder if she would have, if her BLS provider had simply said, "oh toe pain, I'll sit here and spinal immobilize her because protocol says it was given as trauma" and generally pis about because its just a sore leg and  you don't need an education to drive people to hospital.

If you believe in good pt care, you will make the effort to go above and beyond the scope of you EMT education.


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## Sugi (Oct 24, 2009)

Melclin,

Thats exactly what Im trying to do, is go above and beyond my current level of education. Unfortunately, being as I dont have a job in EMS, my resources rely on forums, and ride alongs on a local BRT.


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## Melclin (Oct 24, 2009)

Sugi said:


> Melclin,
> 
> Thats exactly what Im trying to do, is go above and beyond my current level of education..



Evidently. Or you wouldn't be here. Sorry if I sounded like I was having a go. 

We're in the same position you and I, students, trying to make sense of our education without much experience. I've only had a few placements, albeit some mercifully hands on.


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## Sugi (Oct 24, 2009)

At my local school they just implemented a Zero to Hero coarse, which will bring you straight from nothing to Paramedic in about 2-3 years. So I got my EMT-b, but I have almost no experience in the field. Ive had my clinicals and ride alongs, but man is it a chore trying to get through a 2 year paramedic class with no experience.... So any resource I can find, i appreciate. This forums happens to seem like a great one ^_^


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## vquintessence (Oct 24, 2009)

Sugi said:


> At my local school they just implemented a Zero to Hero coarse, which will bring you straight from nothing to Paramedic in about 2-3 years. So I got my EMT-b, but I have almost no experience in the field. Ive had my clinicals and ride alongs, but man is it a chore trying to get through a 2 year paramedic class with no experience.... So any resource I can find, i appreciate. This forums happens to seem like a great one ^_^



I'll go on a limb and assume your Paramedic course is full-time (not a nights or weekend thing).  If that's the case, be happy it's two full years of cirriculum.  Some programs will literally piss out medics in almost 6 months... it's horrifying.

Don't worry a hell of a lot regarding "zero to hero".  I can assure you the zero to hero expression largely came about from a couple groups:
1)  EMT-B's who have been doing it for years and years without expanding to other arenas.  Some will resent those who move up the chain of care provider "too quickly", whether its you becoming a Paramedic, RN, Phlebotomist, etc.
2)  Paramedics/EMTs/RNs/MDs who hear you say "I wasn't in BLS too long so I can't be blamed for not knowing what to do".  Don't *EVER* use that excuse, it's a weak and pathetic argument that screams of immaturity and incompetence.


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## Brandon O (Oct 24, 2009)

Linuss said:


> Now, something to keep in mind, just because there is ST-elevation does NOT mean there is an infarct happening



Lots of other reasons for ST elevation, in my understanding. In fact, injury is not even necessarily the most common cause. Some stats here -- http://ems12lead.blogspot.com/2008/10/problem-of-st-segment-elevation.html


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## daedalus (Oct 24, 2009)

Brandon Oto said:


> Lots of other reasons for ST elevation, in my understanding. In fact, injury is not even necessarily the most common cause. Some stats here -- http://ems12lead.blogspot.com/2008/10/problem-of-st-segment-elevation.html



I doubt that Linuss is suggesting that ST elevation automatically means injury. However, when a 12 lead spits out with some ST elevation, and the patient is clinically suggestive of ACS, my case is pretty solid. The data from studies backs that up as well.

My 12 lead EKG actually will spit out with ***Acute MI*** because of my RBBB.


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## Brandon O (Oct 24, 2009)

daedalus said:


> I doubt that Linuss is suggesting that ST elevation automatically means injury.



No, he was clearly indicating the opposite; we're in agreement and I was just providing some further details 



> However, when a 12 lead spits out with some ST elevation, and the patient is clinically suggestive of ACS, my case is pretty solid. The data from studies backs that up as well.



In my rough and silly EMT brain it seems to me that the four main things one would look for are the ST elevation (in contiguous leads), supporting indicators like reciprocal depression, whether the ECG (or other assessments) suggest another explanation (BBB, etc), and consider their clinical presentation. If all of that lines up you're good to go; even if some of it seems wrong you may still think MI; but in the end you're going to be looking at those things anyway, since they're relevant to treatment decisions whether you believe there's ischemia or no.

But perhaps I'm wrong.


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## daedalus (Oct 24, 2009)

I have been trying to find the study on the number of false positives from field activation of the cath lab. Let me know if you guys can find them.

I think your head is in the right place Brandon.


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## Brandon O (Oct 24, 2009)

daedalus said:


> I have been trying to find the study on the number of false positives from field activation of the cath lab. Let me know if you guys can find them.



Which one -- the one mentioned at the end of the link I gave? (Evaluation of ST segment elevation criteria for the prehospital electrocardiographic diagnosis fo acute myocardial infarction) Or some other?



> I think your head is in the right place Brandon.



I doubt that... yesterday I bumped it yet again getting out of the rig. Seems like it'd be safer somewhere less... protruding...


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## Miss Xina (Oct 26, 2009)

daedalus said:


> Hi Melcin,
> 
> No, the differences between angina and MI are not taught to United States EMT students. Sad, huh?
> 
> ...


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## White Fang (Nov 13, 2009)

The only thing I have to say its that the majority of you need to go back to school and take a course of literature comprehension and listening skills you ripped a part this fellow for just a simple question.......

whats the difference between Angina Pectoris vs Myocardial Infarction... is a simple question on the different sings and symptoms between each other.....

we as emt-b we do not diagnose and emt-p could tell by reading the result on the way to the hospital but you can not tell the difference by the naked eye per say you rely on your S.A.M.P.L.E. History so you can suspect but again our job is to treat not to diagnose the problem.... A few said you can take some classes like A.C.L.S etc.... I am still a student, ill ask, we have a few instructors that are EMT-P and EMT-I but I dought you can just tell if the Patient doesnt tell you specifics.
by the way i read the chapter Cardiac Emergencies before i posted this, it only tells what and why was caused and they do teach us the difference between one and another!!!

Again I think most of you need to READ the question, AND JUST _*ANSWER THE F**** QUESTION*_


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## daedalus (Nov 13, 2009)

White Fang said:


> The only thing I have to say its that the majority of you need to go back to school and take a course of literature comprehension and listening skills you ripped a part this fellow for just a simple question.......
> 
> whats the difference between Angina Pectoris vs Myocardial Infarction... is a simple question on the different sings and symptoms between each other.....
> 
> ...


First of all, how is it my job to treat but not diagnose? How does one go about doing that? Do you know what SOAP is? You need to form an assessment of a patient before moving to the treatment plan. 

Second of all, the attitude is just rude.


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## JPINFV (Nov 13, 2009)

White Fang said:


> we as emt-b we do not diagnose



You're wrong. Read page one of this thread to find out why. On your way through, please note the numerous people who answered the original poster's question regarding MIs and angina.


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## Seaglass (Nov 13, 2009)

The responders that scare me aren't the ones that come to places like this and ask questions. The ones that scare me are the ones that just assume they know it once they graduate and aren't curious enough to look into what they don't know.



daedalus said:


> No, the differences between angina and MI are not taught to United States EMT students. Sad, huh?



My class covered it pretty extensively, but I've run into some that didn't. I even recently encountered a graduating first responder class in a scenario where everyone though my circumferential burn around the wrist was a low-priority transport, and the soot around my mouth was just a distraction from the real injury. The lack of education some emergency workers has is really quite frightening. 

OP: As a student, you're likely to eventually run into topics in the field that just weren't covered in your class, or that were covered too briefly to be of any use. If you had a good textbook, crack it open occasionally and review. If you didn't or want more detail, places like this are great.


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## Lifeguards For Life (Nov 13, 2009)

White Fang said:


> The only thing I have to say its that the majority of you need to go back to school and take a course of literature comprehension and listening skills you ripped a part this fellow for just a simple question.......
> 
> whats the difference between Angina Pectoris vs Myocardial Infarction... is a simple question on the different sings and symptoms between each other.....
> 
> ...



If you only treat and do not diagnose, then you are treating with no idea why. if you don't diagnose before you treat, then you are just randomly performing interventions?


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## White Fang (Nov 14, 2009)

daedalus said:


> First of all, how is it my job to treat but not diagnose? How does one go about doing that? Do you know what SOAP is? You need to form an assessment of a patient before moving to the treatment plan.
> 
> Second of all, the attitude is just rude.





JPINFV said:


> You're wrong. Read page one of this thread to find out why. On your way through, please note the numerous people who answered the original poster's question regarding MIs and angina.





Lifeguards For Life said:


> If you only treat and do not diagnose, then you are treating with no idea why. if you don't diagnose before you treat, then you are just randomly performing interventions?



Well I know this I will be soon an EMT B and my job is to TREAT SIGNS AND SYMPTOMS!!! not diagnose so if you are a EMT I or medic thats a diferent story!

well all i can say is one thing that this is the worst of all forums that I been through and you should just read this annoucement...
http://www.emtlife.com/showthread.php?t=14470

good luck!


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## JPINFV (Nov 14, 2009)

Disagree!=flaming? 

...and if you're "soon an EMT-B," why do you list your training level as "EMT-B?" Shouldn't it be "student?"


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## Shishkabob (Nov 14, 2009)

Whitefang, 

You get called out to a "leg pain" call at the local soccer field where a player was kicked in the shin.  Upon arrival, you see bone protruding out of the players shin.



Is that a break?



Careful!  If you call it a break, you're diagnosing something!


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## Lifeguards For Life (Nov 14, 2009)

If you give me epi as an EMTB, have you diagnosed me as havin anaphylaxis, or are you just giving me epi blindly?


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## Shishkabob (Nov 15, 2009)

If it were me, I'd be giving it because it looked cool.


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## dave3189 (Dec 24, 2009)

All very good points!  However, on the point of the EMTs job not to diagnose... the reality is with a patient experiencing stable angina that resolves with rest and Nitro you would not need to transport.  Therefore in this case, an EMT does need to come up with a Differential.  It is true that when in question treat all cardiac events as worst case scenario (A.M.I) with an ALS response.


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## DrParasite (Dec 24, 2009)

Melclin said:


> PLUS ONE TO JPINFV
> 
> Sugi,
> 
> ...


ok, so what was going on?  first off, I can think of several things wrong with your scenario:

1) why would you spinal immobilize toe pain?  I might not be a paramedic student, but I am pretty sure the toe is several feet from the spine.  it's about as absurd as spinal immobilizing someone with a traumatic injury to a finger.  but again, I am not a paramedic student, so I might need to review my A&P to confirm

2) did she hurt her foot?  as it, did the patient have her toe stepped on?  was it a traumatic foot injury?  or a sudden onset of pain with no history and no known cause?  big difference in what I would be thinking as the cause

3)  you say her face is dry, what about her chest?  is she grossly diaphoretic in her chest, and been drying her face for the past hour?  and what is her pulse rate, and the quality?  you aren't giving enough information about your assessment (yes, BLS are still supposed to do physical assessments) to determine if the patient should go ALS or BLS.

4) lets say it was a traumatic toe injury, did the injury cause the cardiac arrest, or was it just good luck that she arrested in the ambulance?

btw, from this uneducated opinion, based on the very poor assessment you did (because you are missing several key factors about the patient's condition), I would guess that the patient suffered a PE, and by bad luck it made its way to her heart.  Based on the limited info you provided it sounds like a BLS call (again, you are missing several key factors in your assessment so it's a rough guess), and by dumb luck she arrested.  she could have very easily made it to the hospital not in cardiac arrest.  so what was the underlying cause?

back to the OT, angina vs MI is still chest pain to the EMT.  Should they know the difference?  probably.  should they treat them the same?  well, without further tools to properly assess, probably, they should treat it as a chest pain, and call for ALS.


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## Shishkabob (Dec 24, 2009)

dave3189 said:


> the reality is with a patient experiencing stable angina that resolves with rest and Nitro you would not need to transport.



You should ALWAYS try to transport cardiac problems.  How are you able to tell the difference between stable angina and Prinzemetals angina, which is a precursor to sudden death, in the field? You aren't.  If it turns out to be Prinzmetals, they need to see a cardiologist asap.


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## Melclin (Dec 24, 2009)

DrParasite said:


> ok, so what was going on?  first off, I can think of several things wrong with your scenario:
> 
> 1) why would you spinal immobilize toe pain?  I might not be a paramedic student, but I am pretty sure the toe is several feet from the spine.  it's about as absurd as spinal immobilizing someone with a traumatic injury to a finger.  but again, I am not a paramedic student, so I might need to review my A&P to confirm
> 
> ...



EDIT: and now we have a Basic saying they don't necessarily need to transport these patients...you sure as hell wanna know what you're talking about if you think you are going to not transport patients with an obvious cardiac problem and history.


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## Lifeguards For Life (Dec 24, 2009)

Melclin said:


> Speaking of education, how exactly would a PE 'make its way to her heart'? You are talking about a pulmonary embolism aren't you? Explain to me how that happens.



Was wondering that me self?


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## dave3189 (Dec 24, 2009)

If the Angina occurred during exercise or exertion and not at night for example, and the symptoms resolved with rest and nitro prior to your arrival you would not have to necessarily transport... IE: If there is no indication that the angina is unstable or the s/s indicate something more such as an M.I. Patients with stable angina would be taking quite a few rides to the E.R. if they went every time they had an episode.  The patient's opinion as to whether this was a typical episode of "stable" angina for them would be key in making such a decision.


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## Shishkabob (Dec 24, 2009)

dave3189 said:


> If the Angina occurred during exercise or exertion and not at night for example, and the symptoms resolved with rest and nitro prior to your arrival you would not have to necessarily transport... IE: If there is no indication that the angina is unstable or the s/s indicate something more such as an M.I. Patients with stable angina would be taking quite a few rides to the E.R. if they went every time they had an episode.  The patient's opinion as to whether this was a typical episode of "stable" angina for them would be key in making such a decision.





Again, how are you as a basic able to differentiate between stable angina and Prinzmetals by history alone?  You aren't, especially once a vasodialator such as nitro or morphine is administered.  A 12-lead needs to be done before any determination is made... and even then you should try to get your pt to go to the hospital.


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## dave3189 (Dec 24, 2009)

Prinzemetals Angina typically occurs at rest, unlike the more typical presentation where it occurs during one of the "E's".  That being said, I agree with you that you are basing this off of a focused history.  You have given me something to think about and to research into my local protocols.  I am certainly willing to admit when I'm wrong, and freely admit that I am in an infant stage in my EMS career.  Thanks for the insight!


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## zmedic (Dec 24, 2009)

Also remember to ask "why did you call 911 today?" People with stable angina, who get a little out of breath and take their nitro usually aren't calling 911. The fact that you were called means that someone (the patient, the family etc) thought what was going on today was different or worse than usual. That fact alone justifies a transport.


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## JBP (Dec 24, 2009)

This was taught in my EMT calss.  (the difference that is)   The pain of an AMI/MCI is porologed and does not go away with rest.  Pain from an Angina subsides with rest (and of coruse nitro)


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## DrParasite (Dec 26, 2009)

Melclin said:


> Speaking of education, how exactly would a PE 'make its way to her heart'? You are talking about a pulmonary embolism aren't you? Explain to me how that happens.


hmm, what causes a PE?  generally a blood clot....  what are diabetics known for?  having poor circulation in their extremities.  Clot goes from the traumatic toe injury to the heart, causes cardiac arrest.  sometimes it goes to the lung and causes a PE, other times it goes to the heart and causes an MI.  Either way, it sucks for the patient.

Silent MIs happen.  some people live for years without even knowing they had an MI.  I will not say that atypical MIs don't occur because we both know that is not true.  

I never said this patient shouldn't be treated.  but every time you walk into a MD's office they don't throw you on a monitor just in case you are having a silent or a typical MI.  ditto every clinic.  the doctors use the appropriate tools to describe the symptoms.

so ask you self, for every toe pain that you get that turns out to be an MI, how many any just toe pain?  maybe 1000:1? 10000:1?  greater odds?


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## Shishkabob (Dec 26, 2009)

DrP... PE means Pulmonary Embolism... meaning an embolis (or blood clot) in the pulmonic circulation.  It's no longer in the heart.

It's impossible to have a PE in the heart, just as it's impossible to have a stroke in the lungs.


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## JPINFV (Dec 26, 2009)

The capillaries in the lungs makes a pretty good filter to make sure that blood clots starting in the venous system doesn't reach the coronary circulation. Hence any clots larger than, say, a red blood cell, from the veins will cause a PE before it even gets close to anywhere where it can cause a MI.


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## Melclin (Dec 26, 2009)

DrParasite said:


> hmm, what causes a PE?  generally a blood clot....  what are diabetics known for?  having poor circulation in their extremities.  Clot goes from the traumatic toe injury to the heart, causes cardiac arrest.  sometimes it goes to the lung and causes a PE, other times it goes to the heart and causes an MI.  Either way, it sucks for the patient.
> *
> Outstanding. Now hop on wiki, or pick up a middle school science text to see why that is about as likely as me getting a date with Megan Fox. *
> 
> ...



10 characters


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## RescueYou (Dec 31, 2009)

daedalus said:


> Hi Melcin,
> 
> No, the differences between angina and MI are not taught to United States EMT students. Sad, huh?



Oh yes it is! I most definitely learned it.

But as others have mentioned, you are not to diagnose. AMI = heart attack. Easy enough.


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## reaper (Dec 31, 2009)

Soon to be medics, better start learning to diagnose!


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## RescueYou (Dec 31, 2009)

reaper said:


> Soon to be medics, better start learning to diagnose!



Yeah...I'm nervous about that. It just bothers me to know I'll start diagnosing soon.


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## LondonMedic (Jan 2, 2010)

I'm surprised that nobody's mentioned Troponin yet. In this part of the world it's the only univerally accepted way to tell the difference between NSTEMI and unstable angina.


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## LondonMedic (Jan 2, 2010)

JBP said:


> This was taught in my EMT calss.  (the difference that is)   The pain of an AMI/MCI is porologed and does not go away with rest.  Pain from an Angina subsides with rest (and of coruse nitro)


In my experience and knowledge, pain from MI can subside and often does respond to GTN, unstable angina can persist despite rest and the effect of GTN isn't always that dramatic.


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## reaper (Jan 2, 2010)

LondonMedic said:


> I'm surprised that nobody's mentioned Troponin yet. In this part of the world it's the only univerally accepted way to tell the difference between NSTEMI and unstable angina.



In hospital, yes. Very, very few services carry Istat machines on the trucks, so Troponin levels will not be known till in the ED.


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## LondonMedic (Jan 2, 2010)

reaper said:


> In hospital, yes. Very, very few services carry Istat machines on the trucks, so Troponin levels will not be known till in the ED.


So do you not treat as MI with ACS until proven otherwise?


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## Brandon O (Jan 2, 2010)

LondonMedic said:


> So do you not treat as MI with ACS until proven otherwise?



What do you mean by "treat"? The biggest diagnosis-treatment connection here is usually diverting to a STEMI center and activating their cath lab based on ischemic findings in a field ECG. Short of this -- eg. for the BLS guys -- it usually just involves recognizing the common clinical signs, picking the right transport destination and priority, and perhaps aspirin and nitro.

Since there aren't a lot of actual field interventions, except for the relatively few ALS regions that field-administer thrombolytics, the biggest issue of mis- or non-diagnosis is usually failing to recognize the problem and transport with the appropriate speed to the appropriate facility. That's why you see a lot of bickering between medics who want to be recognized with the full authority to "declare" a STEMI in the field, and definitive care who doesn't think they have the training to do so appropriately.

The big deal is how fast we can blow up a balloon in your arteries. Everything else is a pretty distant second place.


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## LondonMedic (Jan 2, 2010)

Brandon Oto said:


> What do you mean by "treat"? The biggest diagnosis-treatment connection here is usually diverting to a STEMI center and activating their cath lab based on ischemic findings in a field ECG. Short of this -- eg. for the BLS guys -- it usually just involves recognizing the common clinical signs, picking the right transport destination and priority, and perhaps aspirin and nitro.


Sorry, I come to this problem as someone with access to lots of drugs, investigations, a cath lab and the facility to transfer for emergency PCI.

As you say - if it looks like an MI, smells like an MI and has ST elevation then transfer to a STEMI centre.

But, in the absence of ST elevation, we would call it Acute Coronary Syndrome and treat symptomatically with diamorph, oxygen and nitrates but load with aspirin, clopidogrel and start enoxaparin before using the trop T (or I) to make the actual diagnosis and determine subsequent management.

You're right, of course, that in EMS the issue is identifying the STEMI and getting it PCI and really that is the end of.


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## Shishkabob (Jan 2, 2010)

It all depends on which part of the US you're in with how they treat ACS'.  Just as we can do cardiac things here that you in the UK cannot, you have a few tools that we do not.


But typically, if it's a cardiac episode, it goes to a cardiac center.


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## LondonMedic (Jan 2, 2010)

Linuss said:


> But typically, if it's a cardiac episode, it goes to a cardiac center.


Are they all emergency PCI centres? We 'save' those for STEMIs requiring PCI (my local one doesn't even have an ER).

Yours seems a reasonable policy except where confusion creeps in about the cause of the chest pain - I've treated plenty of '?MI' diagnoses that have lasted until a CTPA demonstrates a massive PE.


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## Brandon O (Jan 2, 2010)

LondonMedic said:


> But, in the absence of ST elevation, we would call it Acute Coronary Syndrome and treat symptomatically with diamorph, oxygen and nitrates but load with aspirin, clopidogrel and start enoxaparin before using the trop T (or I) to make the actual diagnosis and determine subsequent management.



This is not too different from how I, as a Basic-level provider, would be running such a call in the field, with the obvious exception that I have no idea whether there's ST changes, since I don't have a squiggly box. I'm assessing as fully as possible and moving my butt towards definitive care (and if possible, with squiggly-box-guys arriving prior to that), with oxygen, ASA, and nitrates as my only other tools. The patient may land at the ED with a diagnosis of, say, bad heartburn, they may end up in the cath lab, or they may be somewhere in between. All I'll really know for sure is that it _could have been_ an MI.

The medics obviously have a much better eye on the situation.


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## JPINFV (Jan 2, 2010)

LondonMedic said:


> As you say - if it looks like an MI, smells like an MI and has ST elevation then transfer to a STEMI centre.



Depends... what's the machine interpretation? <_<:wacko:


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## LondonMedic (Jan 2, 2010)

JPINFV said:


> Depends... what's the machine interpretation? <_<:wacko:


Usually artifact


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## JeffDHMC (Jan 3, 2010)

(central, retrosternal pain, tightness, SOB )

+1 for the use of retrosternal as opposed to substernal.


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