Your MI patient may be in denial: Avoid mistriage

Get the details that matter

Is your patient telling you, "It's probably something I ate," "It's nothing," "There isn't any heart history in my family," or "I'm way too young to have a heart problem?"

Many patients with acute coronary syndrome deny that their symptoms are related to a cardiac event, says Wendi Deleon, MS, BSN, RN, assistant chief nursing officer at Northeast Baptist Hospital in San Antonio, TX. "They convince themselves, instead, that they are suffering from some sort of [gastrointestinal] or neurovascular problem," she says.

A patient may give you misleading information, warns Jennifer Conrad, RN, an ED nurse at St. John's Mercy Medical Center in St. Louis, MO. "When patients are not truthful with their symptoms, it makes it very hard to determine what is causing them to come to the ER," she says.

A patient may tell you he is tired, for example, without mentioning shortness of breath or arm pain. "That makes it very hard to determine what is causing those symptoms," says Conrad. "We would have to do EKGs on every patient that came through the door if that was the case."

ID atypical symptoms

"Patients with atypical acute MI [myocardial infarction] symptoms could be overlooked if not triaged appropriately," warns Conrad.

A patient with atypical acute MI symptoms might be mistriaged by a busy ED nurse, says Conrad, adding that two symptoms to watch for are dizziness and recent syncope. "Sometimes patients present with these symptoms because their heart is not perfusing the way it should and they are at risk for acute MI," she says.

Women tend to present differently, says Conrad, and may come in with left arm pain, left jaw pain, or even a feeling of indigestion. "Shortness of breath is also a symptom that should be clinically followed for risk of acute MI," she says. "It's not always the sweaty, pale patient gripping his chest who is having the heart attack."

The goal of the ED nurse should be to "cast a wide net" when assessing patient information that may be cardiac in nature, says Deleon. Chest discomfort, left or right arm discomfort or numbness, jaw pain, weakness, syncope, and vague gastrointestinal symptoms should all be considered cardiac-related until ruled otherwise, she says.

"A more focused review is needed whenever a patient complains of generalized weakness and cold or flu symptoms are not present, especially if the patient is 35 years or older," says Deleon. (See related stories on assessment of chest pain and important questions to ask your patient, below.)


For more information on ED nursing assessment of possible myocardial infarction, contact:

Clinical Tip

Does chest pain go away? Answer is key

Does your patient state that chest pain doesn't go away when he or she lies down? If so, "think possible heart attack," says Wendi Deleon, MS, BSN, RN, assistant chief nursing officer at Northeast Baptist Hospital in San Antonio, TX. Also, ask whether nitroglycerin helped ease the pain. "If nitro does not help, it's probably not cardiac," says Deleon.

Ask these "need to know"questions first

When a patient who is well-known to ED nurses complained of chest pain — something he has reported on numerous prior occasions — he got an EKG within 10 minutes of arrival, says Robert Denton, RN, director of emergency and trauma services at Freeman Health System in Joplin, MO.

The patient was found to have an ST-elevated myocardial infarction, says Denton, and was subsequently sent to the cardiac catheterization lab from the ED.

"This patient could have easily been dismissed as not high-risk, because he had been seen so frequently in the past with no confirmed physical or diagnostic findings," says Denton.

When assessing chest-pain patients, Denton recommends putting information into "need to know" or "nice to know" categories, and asking "need to know" questions first, which the patient can answer with a "yes or no" response. "These are questions that are going to assist in making the decision of where the patient needs to go and how quickly they need to get there," he says.

For instance, says Denton, you need to know if the patient has had severe sweating, immediate onset of nausea and/or vomiting, or any unexplained pain, pressure, fullness, discomfort or heaviness in the chest or abdominal area, or shortness of breath.

The "nice to know" questions, says Denton, include a history of coronary artery or vascular disease, a family history of heart disease, smoking history, hypertension, diabetes, drug use (both prescribed and non-prescribed), history of cerebral vascular accident or transient ischemic attack, and surgical history.

"The care plan is always in a state of adjustment, as additional information becomes known and the patient status evolves," says Denton.