Don't assume your patient is too young to have an MI
A 30-year-old man complained of chest pain to ED nurses at Cleveland Clinic and reported no history of cardiac disease or hypertension, but he said he was a current smoker.
"He said he rehabbed houses for a living and thought it was musculoskeletal pain," says Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for emergency and critical care services. "His forehead showed only a very fine perspiration." Vital signs indicated a heart rate of only 32, however.
The man was immediately given an electrocardiogram (EKG), which revealed an inferior wall myocardial infarction (MI). "Aspirin was given and heparin started. No beta-blocker was given because of the low heart rate," says Fielden. "He was taken to the cath lab, with a door-to-cath lab time of 17 minutes."
If a patient younger than 45 has symptoms suggesting a possible MI, would you possibly overlook this diagnosis due to the patient's age? Patients under 45 actually comprise 10% of MIs, according to a new study, which says risk factors are different for younger patients.1
The youngest patients in the study, ages 18 to 45, had less diabetes, hypertension, and history of MI than older patients, and they were more likely to be male, nonwhite, current smokers, and obese. "Our chest pain guidelines require an EKG on anyone age 30 or older presenting with chest pain or other anginal symptom," says Fielden.
In addition, adolescent athletes should receive a cardiology consult when presenting with syncope, dyspnea, or dizziness with exercise, says Fielden. "Although sudden cardiac death is rare, they could have a form of structural nonatherosclerotic heart disease, congenital or acquired."
Regardless of age, ask all patients if they have a history of high blood pressure, heart problems, or diabetes and if there is current substance abuse including amphetamines or cocaine, advises Jennifer Williams, RN, BC, M-S CNS, CEN, CCRN, a clinical nurse specialist at Barnes-Jewish Hospital in St. Louis. "If they screen positive for any of those and they have cardiac complaints including chest pain, nausea, general abdominal pain, or fatigue in women, then we give them an EKG," says Williams.
Recently, ED nurses cared for a 34-year-old man who had started experiencing chest pain while playing basketball. "His only concerning past medical history was a grandparent with a history of a heart attack," says Williams.
Nurses did an immediate EKG, which revealed an MI. The patient was immediately moved to the critical patient area and sent to the cath lab within 20 minutes.
Williams also cared for a 37-year-old MI patient who was a smoker with a family history of a parent having a heart attack. "Because the nurse receiving the call from EMS recognized that he was at higher risk due to family history and his smoking status, an EKG was done immediately and he proceeded to the cath lab," she says.
Reference
- Anderson RE, Pfeffer MA, Thune JJ, et al. High-risk myocardial infarction in the young: The VALsartan in Acute myocardial iNfarcTion (VALIANT) trial. Am Heart J 2008; 155:706-711.
Sources
For more information on younger patients with myocardial infarction, contact:
- Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, Emergency & Critical Care Services, Cleveland Clinic. Phone: (216) 444-0153. Fax: (216) 444-9734. E-mail: [email protected].
- Jennifer Williams, MSN, RN, ACNS-BC, CEN, CCRN, Clinical Nurse Specialist, Emergency Services, Barnes-Jewish Hospital, St. Louis. Phone: (314) 747-8764. Fax: (314) 362-2495. E-Mail: [email protected].
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