Date Published

July 5, 2024

Updated For

ALS PCS Version 5.3


Why ASA 1st?

  • ASA has proven mortality reduction in cardiac ischemia
  • Nitro has no proven mortality benefit in cardiac ischemia (however, it can improve symptoms)

THEREFORE, ASA should be administered before nitro!

A Legible 12-Lead ECG Should be Obtained Prior to Nitro Administration

  • If unobtainable, withhold nitro and document​
  • If illegible, you cannot accurately determine if and where a STEMI may be located. Try to reduce artifact and re-attempt. 
  • Nitro administration may cause significant hypotension in the setting of Right ventricular MIs due to the pathophysiology of injury to this myocardial territory and inability to compensate for the vasodilation
  • Administering nitro to a patient with an illegible 12-Lead ECG is a "Level B" variance as it may compromise patient safety

Bottom Line

Nitro administration can help patient symptoms in suspected cardiac ischemia; HOWEVER, it should be considered only after:

1) ASA: Aspirin has mortality benefit in cardiac ischemia, whereas nitro does not 

2) Legible 12-Lead ECG is obtained: This ensures patient safety by confirming the contraindication of “12 lead compatible with right ventricular MI” is NOT present 

Stay tuned for more on this topic as part of the #SWORBHPtips series on cardiac ischemia 


Additional Resources:

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