Cardiac ischemia vs Chest pain

The medical directive titled Cardiac Ischemia is worded as such to help encompass all types of cardiac ischemia, including some that you mentioned such as chest pain, weakness or dyspnea, but also nausea, vomiting, diarrhea, indigestion, diaphoresis, fatigue, irregular heartbeats, and even “just feeling off”. Cardiac ischemia can present itself in many ways across various patient populations. More specifically, older women and those with diabetes are well-known to present differently, sometimes completely pain-free.

Nitroglycerine (NTG) use is recommended for all patients that are presenting with suspected cardiac ischemia if they fit within the conditions and contraindications of the medical directive. It is however important to note that NTG is a symptom relief medication that has not demonstrated changes in a patient’s morbidity or mortality. It is used to help alleviate patient discomfort. If you are in doubt about using it or if it is showing to have no effect, consider withholding use. Additionally, if you are in doubt, consider a consultation patch to a base hospital physician or withhold treatment. Furthermore, ASA should also always be considered for these patients as it is known to have a wide therapeutic index. In cases of acute coronary syndrome (ACS), the literature recommends an initial loading dose of 162 to 325 mg of ASA, administered once, unless contraindications are present (per the ALS PCS). Aspirin use has been shown to reduce ischemic events and the risk of coronary artery re-occlusion, with some studies suggesting a 23% reduction in cardiovascular mortality.

Please note that an abnormal ECG reading with no associated symptoms is not an indication for NTG use. However, if ever faced with this type of situation, consider an even deeper dive into their medical and current event history to see if something got missed.