Cardiac Ischemia Treatment
Question# 783
Under the Cardiac Ischemia MD, is there ever a case in which it is acceptable to give ASA but not NTG (assuming conditions/contraindications are met for both)?
We often see otherwise healthy patients who describe a mild to moderate, non-reproducible CP but have no features of shock, no ST changes or other ECG concern, with V/S WNL. Because of this "non-reproducible CP," the patient is generally treated as cardiac ischemia and provided ASA, NTG, and given a code 4, CTAS 2 trip to hospital, just to sit on offload delay.
I realize this is a very case-by-case scenario but is it reasonable to use clinical judgement in saying that in the aforementioned patient may receive ASA "just in case," but that NTG and a code 4 drive may not be necessary. ASA has low risk, high benefit; NTG has more risk with arguably less benefit to the overall outcome of patients. Not to mention if giving NTG also means the patient requires IV cannulation to meet conditions, yet another potential risk.
We often see otherwise healthy patients who describe a mild to moderate, non-reproducible CP but have no features of shock, no ST changes or other ECG concern, with V/S WNL. Because of this "non-reproducible CP," the patient is generally treated as cardiac ischemia and provided ASA, NTG, and given a code 4, CTAS 2 trip to hospital, just to sit on offload delay.
I realize this is a very case-by-case scenario but is it reasonable to use clinical judgement in saying that in the aforementioned patient may receive ASA "just in case," but that NTG and a code 4 drive may not be necessary. ASA has low risk, high benefit; NTG has more risk with arguably less benefit to the overall outcome of patients. Not to mention if giving NTG also means the patient requires IV cannulation to meet conditions, yet another potential risk.
Answer:
In short, if the patient is not complaining of chest pain, there is no role for administering NTG. The similar analogy can be applied to analgesia: if the patient is not in pain, we don’t administer analgesia.
Nitro is a medication that provides symptom relief through vasodilation, is certainly helpful for patients with who are hypertensive with CHF, it can help for cocaine induced chest pain but there’s no mortality benefit shown. There are also downsides and risks of nitro given its ability to produce hypotension, and we’d want to withhold it for patients who are pre-load dependant (aortic stenosis, RV infarct, inferior MI, etc.).
Unless the patient has a contraindication to ASA, it should be administered to all patients we suspect of having an ischemic event. ASA has a huge mortality benefit, with an exceptional number needed to treat, a wide therapeutic window, and a low risk profile.
With respect to your comment about reproducible chest pain, this one is a bit trickier. It’s important to understand that just because a patient has reproducible chest pain, this doesn’t preclude them from having a sinister event. I encourage you to read a previously published MedicASK or listen to the Critical Levels Podcast around ACS in MedicLEARN for a more detailed read/listen about this exact topic.
As per the Prehospital CTAS guide, CTAS 2 patients are to be transported to the nearest/closest most appropriate receiving facility based on communication between paramedics, dispatch, and the receiving facility. This patient would be classified as a CTAS 2.
You play a critical role in this decision, as you have the most intimate knowledge of the patient’s needs. Please continue to voice your perspectives when discussing disposition. Driving Code 4 puts yourself, your patient, your partner, and other users of the road at risk, and often has a negligible impact on transport times. The decision to drive Code 4 (lights and sirens) is at the paramedic’s discretion and may be based on several factors such as traffic, distance to the receiving facility, patient presentation and dynamics of the chief complaint. Clinical decision making is important and should consider patient stability, hemodynamics, and time-sensitive interventions at the ED (i.e. STEMI requiring angioplasty, cardiogenic shock, CHF requiring PPV, PTX requiring chest tube insertion, etc.)
In summary: ASA has significant benefit with minimal risk, and its administration is encouraged when there is no contraindication. Conversely, nitrates are a symptom relief medication that have little to no effect on outcome. This should be balanced with patient comfort (i.e. relieving the pain), but if you feel there is a reason to withhold (i.e. borderline BP) or discontinue (absence of efficacy/causing unwanted effects such as headache), we support that clinical decision. As always, please ensure your rationale is clearly outlined in the remarks section for those further along in the circle of care.
Nitro is a medication that provides symptom relief through vasodilation, is certainly helpful for patients with who are hypertensive with CHF, it can help for cocaine induced chest pain but there’s no mortality benefit shown. There are also downsides and risks of nitro given its ability to produce hypotension, and we’d want to withhold it for patients who are pre-load dependant (aortic stenosis, RV infarct, inferior MI, etc.).
Unless the patient has a contraindication to ASA, it should be administered to all patients we suspect of having an ischemic event. ASA has a huge mortality benefit, with an exceptional number needed to treat, a wide therapeutic window, and a low risk profile.
With respect to your comment about reproducible chest pain, this one is a bit trickier. It’s important to understand that just because a patient has reproducible chest pain, this doesn’t preclude them from having a sinister event. I encourage you to read a previously published MedicASK or listen to the Critical Levels Podcast around ACS in MedicLEARN for a more detailed read/listen about this exact topic.
As per the Prehospital CTAS guide, CTAS 2 patients are to be transported to the nearest/closest most appropriate receiving facility based on communication between paramedics, dispatch, and the receiving facility. This patient would be classified as a CTAS 2.
You play a critical role in this decision, as you have the most intimate knowledge of the patient’s needs. Please continue to voice your perspectives when discussing disposition. Driving Code 4 puts yourself, your patient, your partner, and other users of the road at risk, and often has a negligible impact on transport times. The decision to drive Code 4 (lights and sirens) is at the paramedic’s discretion and may be based on several factors such as traffic, distance to the receiving facility, patient presentation and dynamics of the chief complaint. Clinical decision making is important and should consider patient stability, hemodynamics, and time-sensitive interventions at the ED (i.e. STEMI requiring angioplasty, cardiogenic shock, CHF requiring PPV, PTX requiring chest tube insertion, etc.)
In summary: ASA has significant benefit with minimal risk, and its administration is encouraged when there is no contraindication. Conversely, nitrates are a symptom relief medication that have little to no effect on outcome. This should be balanced with patient comfort (i.e. relieving the pain), but if you feel there is a reason to withhold (i.e. borderline BP) or discontinue (absence of efficacy/causing unwanted effects such as headache), we support that clinical decision. As always, please ensure your rationale is clearly outlined in the remarks section for those further along in the circle of care.