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Heart disease has been the leading cause of death in America for over 80 years. An estimated 935,000 people in America suffer a myocardial infarction each year at an estimated annual cost of $151.6 billion.1,2 Although the development of EMS is often ascribed as a response to America's shocking rates of morbidity and mortality from motor vehicle accidents, emergency cardiac care has also driven EMS development and in many ways has become the central mission of modern EMS. From some of the first work on prehospital cardiac care as published by Frank Pantridge et al in 19673 to large multisystem studies of cardiac arrest survival published in the past few years, it is clear that much progress has been made. Yet the basic tenets of prehospital cardiac care remain simple: identification of the patient with a cardiac emergency; stabilization; selection of an appropriate receiving facility; safe and timely transport to that facility.


  • Understand the goals of prehospital treatment for patients with acute coronary syndrome.

  • Discuss destinations, including options for treatment as well as transfer.

  • Learn about treatment options for patients diagnosed with arrhythmias.

  • Consider high-risk patients and special cardiac situations and equipment.

  • Discuss other etiologies of chest pain and approaches for these patients.



The prehospital approach to the ACS patient begins with identification of potential patients. Emergency medical dispatch (EMD) has been designed to assist with this, but these programs tend to overtriage and, as they rely on data from the lay public, can also fail to identify ACS patients.4 For this reason, any dispatched chief complaint suggestive of ACS should be considered as such until it can be properly verified.

Upon arrival, scene safety is always the first step after which a brief scene size-up should be conducted to ensure that adequate equipment and resources are either present or have been requested. After quickly assessing airway, breathing, and circulation, it is essential that a focused history and physical examination be obtained, even if the patient has classic complaints of left-sided chest pain and shortness of breath.

If a patient is complaining of atraumatic chest pain, he or she should be placed on a cardiac monitor and 12-lead ECG obtained. Prehospital ECG has been shown to improve outcomes in patients with STEMI and non-STEMI patients.5 IV access should be attempted and appropriate medical therapy started. Package the patient for transport, and transport the patient to the most appropriate facility. The patient needs to be monitored throughout the call for signs of deterioration, with changes in patient status addressed promptly (Table 39-1).

TABLE 39-1

Standard Approach to the ACS Patient

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