10% of heart attacks go untreated: Don't let this happen in your ED

Emergency department nurses are 'critical link'

If a patient walked into your ED having a heart attack, could that patient be discharged without receiving life-saving interventions?

More than 10% of eligible heart attack patients may not receive potentially life-saving treatment in the ED, says a new study.1 Researchers looked at 238,291 patients from the National Registry of Myocardial Infarction who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention (PCI), and they found that 11.6% were untreated.

"ED nurses may be the critical link between patients and appropriate care," says Brahmajee K. Nallamothu, MD, MPH, the study's lead author and assistant professor of internal medicine in the Division of Cardiology at University of Michigan Medical School in Ann Arbor.

This link is especially true for patients who come to the ED with subtle or atypical symptoms, according to Nallamothu. "I think three particularly important groups that ED nurses can make a large impact on are patients who present without classic chest pain, patients who present late after symptom onset, and those who drive themselves to the hospital," he says. For example, an elderly diabetic woman with no prior history of coronary artery disease who comes to the ED hours after symptom onset with shortness of breath, rather than angina, would probably get less attention up front by providers, says Nallamothu.

These heart attack patients are at high risk for not receiving treatment in the ED:

  • Patients with subtle or atypical symptoms.

Patients without chest pain or those whose electrocardiograms (ECGs) have fewer leads with ST-elevation were less likely to be treated in the study. "This may be because clinicians were unclear early on about the diagnosis," says Nallamothu.

Watch for subtle symptoms of heart attack, especially in women, says Lisa Medina, BSN, RN, program manager at St. John Heart Institute in Tulsa, OK. "If individuals present with any kind of pain between the naval and the jaw, heart attack should be considered," she says. "You particularly want to pay attention to middle-aged women who complain of shoulder pain and back pain."

A 40-year-old woman presenting to the ED with increasing fatigue over the past month and severe epigastric distress unrelieved by antacids may receive several diagnostic tests before an ECG is performed, says Medina. "With time of the essence in restoring myocardial perfusion, it is imperative to determine if symptoms are cardiac-related as soon as possible," she emphasizes.

Say the following at triage, advises Medina: Describe the pain or discomfort. What precipitated the pain? How is the pain relieved? Has the pain been experienced before?

Heart attack patients may report shortness of breath and nausea with no accompanying pain, says Medina. "Women often report pain or discomfort between the shoulder blades. Occasionally you get jaw pain with nothing else, and epigastric distress is fairly common," she says. "People may have self-treated with antacids prior to arrival."

Watch for nonverbal clues, such as a patient placing a closed fist to the chest or rubbing the chest in a generalized fashion, says Medina. "If someone can directly point to a place of pain and the pain is affected by moving an extremity or the chest wall, it may be musculoskeletal in origin," she says.

Emergency nurses at St. John obtain an ECG at triage for any patient complaining of chest pain or any of the above complaints, says Medina. "We try to err on the side of caution. We would rather obtain a normal ECG than miss an abnormal ECG," she says. (See steps taken for heart attack patients by ED nurses below.)

Heart Attack Patients in the ED

1. Ensure the patient has two patent intravenous lines.
2. Hang 5% dextrose/1/2 normal saline at keep vein open     rate.
3. Start Heart Start Medication protocol per physician     order.
4. Obtain electrocardiogram. Repeat if transmitted by     ambulance system prior to arrival.
5. Draw labs.
6. Apply electrocardiogram monitor patches used in cath     lab.
7. Apply hands-off radio-lucent defibrillation pads.
8. Shave and clean both groins.
9. Mark pulses on feet.

Source: St. John Heart Institute, Tulsa, OK.

Assume that any cardiac pain is a myocardial infarction until proven otherwise, says Heather Freiheit, RN, BSN, EMT-P, clinical manager of emergency services at Rogue Valley Medical Center in Medford, OR. "The saying 'time is muscle' still holds true," she says.

Women are especially vulnerable to being mistriaged, because they often don't have "typical" heart attack signs and symptoms, says Freiheit. "Women frequently present with abdominal pain, generalized weakness, nausea, and vomiting, which can be overlooked as flulike symptoms," she says. "These are the subtle things that an inexperienced nurse may overlook."

To identify atypical symptoms, you must be "very keyed into" the patient's history and physical, says Kathleen Menard-Murray, RN, BSN, CEN, ED clinical leader at Caritas St. Elizabeth's Medical Center in Boston. "Women in particular may have shortness of breath; epigastric pain; neck, back, arm, shoulder pain; or no pain at all," she says. "Diabetics typically do not have any chest pain at all, so any associated symptoms would be a signal to get an ECG right away." Those symptoms include shortness of breath, nausea, palpitations, tachycardia, and diaphoresis, says Menard-Murray. "Any woman over the age of 40 with epigastric or upper abdominal pain we consider to be a possible cardiac event," she says.

If the patient has other risk factors, such as a strong family history of cardiac disease, is a smoker, or has high cholesterol, the threshold for obtaining an ECG within 10 minutes of arrival in the ED is lowered, says Menard-Murray.

"Diabetics and women are the ones that you really need to ask further questions and err on the side of caution," says Menard-Murray. "Give aspirin, oxygen, beta-blockers, and get them to the cath lab right away if their ECG reveals an ST-elevation MI [STEMI]," she says.

  • Elderly patients.

Elderly heart attack patients in the study were less likely to be treated. This lack of treatment may be because nurses are inappropriately assessing the risks and benefits of therapy in this group, says Nallamothu.

"Clinicians may be concerned that these patients are at risk for bleeding," says Nallamothu. "But current evidence suggests that the elderly do benefit from these treatments, often due to their high overall risk of complications after STEMI."

An elderly diabetic woman may certainly be at risk for bleeding complications, particularly if she is frail or does not weigh much, says Nallamothu. "However, she will also be the most likely to benefit from treatment with fibrinolytic therapy or PCI, given her very high overall risk of death if she remains untreated."

  • Patients who downplay their symptoms.

"Many patients are 'minimizers,' that is, they discount their symptoms," says Nallamothu. "These may be the patients that often present several hours after symptom onset and can get overlooked, particularly when the ED is busy."

Instead of asking patients about "chest pain" specifically, ask if they are having any "discomfort," advises Medina. "Many people have varying definitions of pain and may experience only pressure or aching," she says.

Your No. 1 goal should be to see that these patients receive an immediate ECG, says Nallamothu. "ED nurses play a critical role in ensuring that these tests get done and interpreted in a timely manner," he adds.


1. Nallamothu BK, Blaney ME, Morris SM, et al. Acute reperfusion therapy in ST-elevation myocardial infarction from 1994-2003. Am J Med 2007; 120:693-699.


For more information on heart attack care in the ED, contact:

  • Heather Freiheit, RN, BSN, EMT-P, Clinical Manager, Emergency Services, Rogue Valley Medical Center, 2825 E. Barnett Road, Medford, OR 97504. Phone: (541) 789-7120. E-mail: HFreiheit@asante.org.
  • Lisa Medina, BSN, RN, Program Manager, St. John Heart Institute, 1923 S. Utica, Tulsa, OK 74104. E-mail: emedina@sjmc.org.
  • Kathleen Menard-Murray, RN, BSN, CEN, Clinical Leader, Emergency Department, Caritas St. Elizabeth's Medical Center, 736 Cambridge St., Boston, MA 02135. Phone: (617) 789-3000. E-mail: Kathleen.Menard-Murray@caritaschristi.org.
  • Brahmajee K. Nallamothu, MD, MPH, Assistant Professor, Internal Medicine, Division of Cardiology, University of Michigan Medical School, B1-226 Taubman Center, Ann Arbor, MI 48109. Phone: (734) 936-7375. Fax: (734) 764-4142. E-mail: bnallamo.intmed1.po-02@med.umich.edu.