Presented by
\T\
Naglaa Abuelzahab
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According to the Centers for Disease Control
(CDC), heart disease is the leading cause of
death for both men and women.
Approximately 600,000 Americans die from
heart disease each year, which represents one
in every four deaths.
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Coronary artery disease (CAD) is the most
common type of heart disease and is
responsible for more than 385,000 deaths
each year. A key to effective treatment of the
patient is early recognition that the patient is
suffering from a condition involving the heart
and advanced cardiac care delivered within
the first few hours after the patient
experiences the first symptom of a cardiac
problem.
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Time is a critical element in the survival and
improved outcome of many of these patients.
Death of a portion of the heart muscle is
permanent and irreversible. Thus, it is important for you as an EMT to recognize the signs
and symptoms of the many possible cardiac
conditions, referred to collectively as cardiac
compromise, and to provide emergency care
and expeditious transport to a medical facility
that is prepared to manage a patient with
such a condition.
is a condition that causes the smallest of
arterial structures to become stiff and less
elastic.
Atherosclerosis is a systemic arterial disease.
Atherosclerosis is an inflammatory disease that
starts with the intimal (innermost) lining of the
blood vessels, where endothelial cells become
damaged
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Atherosclerosis is the buildup of calcium and
cholesterol in the arteries.
 Can cause occlusion of arteries
 Fatty material accumulates with age.
 When a patient has a buildup of fatty deposits
(atherosclerosis) on the inside of the coronary
arteries, the condition is called coronary
artery disease (CAD)
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The narrowing of the coronary blood vessel
increases the resistance to blood flow
through the artery and decreases the amount
of blood flow to the distal heart muscle. The
fatty deposits reduce the coronary arteries’
ability to dilate (become larger) and deliver
additional blood flow to the heart when
needed, such as in an increase in heart rate
or more forceful pumping action.
results from a variety of conditions that can
affect the heart in which the coronary arteries
are narrowed or occluded by fat de posits
(plaque), clots, or spasm.
 The word acute refers to a sudden onset,
coronary refers to a condition affecting the
coronary arteries, and syndrome indicates a
group of signs and symptoms produced by
the condition.
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Two conditions that are part of any acute
coronary syndrome are unstable angina and
myocardial infarction (heartattack).
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Angina pectoris (which means, literally, “pain
in the chest”) is a symptom commonly
associated with coronary artery disease.
Unstable angina has a variety of definitions,
but usually indicates angina discomfort that
is prolonged and worsening, or that occurs
without exertion and when the patient is at
rest.
Angina pectoris is a symptom of inadequate
oxygen supply to the heart muscle, or
myocardium
 Generally, angina pectoris occurs during
periods of stress, either physical or
emotional. Once the stress is relieved or
removed or the patient rests, the pain will
usually go away
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Ensure a patent airway and provide positive
pressure ventilation with oxygen connected
to the device if the breathing is inadequate.
 If the respiratory rate and tidal volume are
both adequate, consider supplemental
oxygen
 administer supplemental oxygen if the
patient is dyspaneic, hypoxemic, has obvious
signs of heart failure, has an SpO2 reading of
<94%, or the SpO2 is unknown.
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Characteristics of angina pain
The pain is usually felt under the sternum
and may radiate to the jaw, down either arm,
to the back, or to the epigastrium (upper
center region of the abdomen)
The pain usually lasts for about 2–15 min
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Assessment. The signs and symptoms of angina
pectoris are similar to those of any cardiac
compromise and may include the following:
Women, diabetics, and the elderly may not have
the typical presentation of signs and symptoms
of angina. The discomfort may appear to be more
diffuse or may be described more vaguely. These
patients may not have any chest pain or
discomfort but may instead complain of
shortness of breath, fainting, weakness, or lightheadedness.
should be provided whether signs and
symptoms of an acute coronary syndrome
emergency exist or not.
 You should establish an open airway. If the
patient’s respirations become inadequate,
begin positive pressure ventilation.
 Apply the pulse oximeter, if available, to
monitor the oxygen level.
 administer supplemental oxygen if the patient
is dyspaneic, hypoxemic, has obvious signs of
heart failure, has an SpO2 reading of <94%, or
the SpO2 is unknown.
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Administer oxygen via a nasal cannula at 2 to
4 lpm and titrate the concentration and liter
flow to achieve and maintain an SpO2 of
>94%
 . If the patient has prescribed nitroglycerin
and his systolic blood pressure is greater
than 90 mmHg, place him in a sitting or lying
position and administer the nitroglycerin
tablets or spray.
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An acute myocardial infarction (AMI) occurs
when a portion of the heart muscle dies
because of the lack of an adequate supply of
oxygenated blood.
Acute means sudden, myocardial refers to
heart muscle, and infarction refers to death
of tissue. An acute myocardial infarction is
what the layperson refers to as a heart attack.
Assessment. Chest discomfort is the most 
significant symptom of a heart attack. The
discomfort the patient experiences is similar
to that of angina; however, the symptoms last
longer. Also, chest discomfort from an acute
myocardial infarction will be only partially
relieved with nitroglycerin or not relieved at
all.
The boundaries between unstable angina and AMI are not
so distinct, and it may be difficult to distinguish between
the two conditions.
Signs and symptoms of AMI include the following: • 
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Chest discomfort radiating to jaw, arms, shoulders,
or back •
Anxiety •
Dyspnea
Sense of impending doom •
Diaphoresis •
Nausea and/or vomiting •
Lightheadedness or dizziness
•Weakness
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you should proceed rapidly with your
assessment and management of the patient.
This patient has the potential to go into
cardiac arrest; therefore, you should
frequently assess the patient and maintain a
vigilant watch over the patient’s condition. If at
all possible, the patient should never be left
alone while you are returning equipment to the
EMS unit or retrieving and preparing
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Ensure a patent airway and provide positive
pressure ventilation with oxygen connected
to the device if the breathing is inadequate
 administer supplemental oxygen if the
patient is dyspneic, hypoxemic, has obvious
signs of heart failure, has an SpO2 reading of
<94%, or the SpO2 is unknown.
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. Administer oxygen via a nasal cannula at 2
to 4 lpm and titrate the concentration and
liter flow to achieve and maintain an SpO2 of
>94%
 The AHA 2010 guidelines indicate that there
is not sufficient evidence to support the use
of supplemental oxygen as a routine in
patients who do not present with dyspnea,
hypoxemia, heart failure, or an SpO2 of
<94%. Do not overoxygenate the patient.
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Place the patient in a position of comfort.
 If the patient has a prescription for
nitroglycerin, administer one tablet every 3–5
minutes up to a total of three tablets
 Be sure the systolic blood pressure is above
90 mmHg and remains above 90 mmHg
following each nitroglycerin administration.
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If the patient becomes pulseless and apneic
(no pulse, no respirations), immediately begin
cardiac resuscitation and apply the
automated external defibrillator
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Two types of lifethreatening injuries may
occur to the aorta that are often confused
with each other: aortic aneurysm and aortic
dissection.
with each other: aortic aneurysm and aortic
dissection. Both can cause pain that may be
confused with the pain of myocardial
infarction.
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Aortic aneurysm occurs when a weakened
section of the aortic wall, usually resulting
from atherosclerosis, begins to dilate or
balloon outward from the pressure exerted
by the blood flowing through the vessel.
An aneurysm may exist for a long time with
no symptoms or signs that the patient is
aware of, then suddenly rupture, causing
rapid and fatal internal bleeding
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Aortic aneurysms occur most often in the
abdominal region. Pain may be felt, especially
in the back, when the aneurysm gets large
enough, perhaps .
shortly before rupture occurs. Usually, the
aorta cannot be felt on physical examination,
but at this final stage it may be felt as a
pulsating mass in the abdomen, al though
this may be difficult or impossible to detect
in a heavyset patient.
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Aortic dissection occurs when there is a tear
in the inner lining of the aorta and blood
enters the opening and causes separation of
the layers of the aortic wall.
Aortic dissections occur most often in the
area of the thorax. The pain is classically
most severe when the dissection first occurs
and is most often described as “sharp” pain,
or sometimes as a “tearing” or “ripping” pain,
often felt in the back, flank, or arm. Syncope
may be the only sign in some patients.
it may cause symptoms similar to stroke or
to myocardial infarction and, in fact, may lead
to a myocardial infarction or other damage to
the heart
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A difference of 20 mmHg or greater in the
systolic blood pressure reading be tween the
upper arms or a severe decrease or
difference in the upper and lower extremity pulse
amplitude as compared to central pulses in a
patient complaining of back or sharp chest pain
should cause you to suspect a possible aortic
dissection.
If a pulsating mass is felt and aortic aneurysm is
suspected, administer oxygen and transport the
patient immediately, as only surgery can prevent
or repair rupture of the aneurysm.
 For a chest or back pain that may result from an
aortic dissection or that may be a symptom of
myocardial infarction, administer oxygen and
assist the patient with prescribed nitroglycerin if
the blood pressure is greater than 90 mmHg and
no signs of hypovolemia are present. If aortic
dissection is suspected, do not administer aspirin.
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When the heart no longer has the ability to
adequately eject blood out of the ventricle, it
is considered to be failing.
Heart failure may also be caused by a valve
disorder, hypertension, pulmonary embolism,
cardiac rhythm disturbances, and certain
drugs.
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Assessment The signs and symptoms of heart
failure depend on the severity of the
condition and whether it is an acute onset or
a longterm problem
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The signs and symptoms of heart failure include
the following:
Marked or severe dyspnea (shortness of breath)
 Tachycardia (rapid heart rate greater than 100
bpm) •
 Difficulty breathing when supine (orthopnea)
 Suddenly waking at night with dyspnea
(paroxysmal nocturnal dyspnea)
 Fatigue on any type of exertion
 Anxiety
 Tachypnea (rapid respiratory rate)
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Crackles and possibly wheezes on
auscultation
 Decreased SpO2 reading •
 Signs and symptoms of pulmonary edema
 Blood pressure may be normal, elevated, or
low •
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Distended neck veins—jugular venous
distention (JVD) (late) (Figure 1715 ■) •
Distended and soft spongy abdomen
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Ensure the patient has a patent airway.
Provide positive pressure ventilation with
supplemental oxygen connected to the device
if the breathing is inadequate.
If the patient has an adequate respiratory rate
and tidal volume, administer supplemental
oxygen.
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According to the AHA 2010 guidelines,
administer supplemental oxygen if the
patient is dyspneic, hypoxemic, has obvious
signs of heart failure, has an SpO2 reading of
<94%, or the SpO2 is unknown. Administer
oxygen via a nasal cannula at 2 to 4 lpm and
titrate the concentration and liter flow to
achieve and maintain an SpO2 of >94%. Apply
a non rebreathe mask at 15 lpm if severe
hypoxia is present.
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If the patient is experiencing chest discomfort
and has a prescription for nitroglycerin,
administer one tab let every 3–5 minutes to a
total of three tablets.
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A hypertensive emergency is defined as a
severe, accelerated hypertension episode with
a systolic pressure greater than 160 mmHg,
and/or a diastolic blood pressure greater
than 94 mmHg.
Hypertension usually does not produce any
clinical findings until there are vascular
changes to the heart, brain, lungs, or
kidneys.
Assessment. Signs and symptoms of a
hypertensive emergency are:
•Strong, often bounding pulse •
 Skin that may be warm, dry, or moist
 Severe headache •
 Ringing in the ears •
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Nausea and/or vomiting
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Elevated blood pressure •
 Respiratory distress •
 Chest pain •
 Seizures •
 Focal neural deficits •
 Indications of organ dysfunction (stroke,
heart attack, pulmonary edema)
•
Possible nosebleed
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Oxygen administration should be guided by the
SpO2 reading, signs and symptoms of a possible
under lying condition, and signs of hypoxia in a
patient with adequate breathing.
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The patient should also be placed in a position of
comfort, but encourage a semiFowler’s position if
there are no airway concerns.
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If you suspect the hypertensive patient might
be having a stroke, the blood pressure will
not be lowered in the prehospital setting;
thus, it may not be prudent to delay transport
to wait for ALS.
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Finally, provide emotional support and
reassurance while transporting the patient.