Can I Rule Out Ischemia?​

Cardiac ischemia can present with many different symptoms, including “atypical” complaints .​

​Non-exhaustive list of signs and symptoms:​​

• Chest pain ​​
• Radiation of pain to one of both upper extremities and jaw​​
• Dyspnea​​
• Nausea/vomiting​​
• Diaphoresis ​​
• Unexplained fatigue

Although some signs and symptoms are more predictive of ischemia (ex. crushing chest pain with radiation to one or both arms) – there is no way to RULE-OUT ischemia without tests in-hospital. ​​

​The following do not rule out cardiac ischemia:​

• 12-Lead ECG with no  STEMI identified​​
• Pain on palpation​​
• Pain on inspiration​​
• Pain that worsens with position change

​

A recent Ask MAC (posted Sept 13, 2023) highlights this question of whether a paramedic in the field can rule out ischemic chest pain due to it being reproducible. ​​

​The answer echoes this post and notes up to 15% of patients ultimately diagnosed with acute MI reported chest wall pain or reproducible pain. 

Cardiac Ischemia DDx​

When deciding if you think your patient may be experiencing cardiac ischemia, consider all your findings together, including:​

• Patient’s presenting story​​
• PMHx​​
• Vital Signs​​
• Patient appearance ​
• Full physical exam

In Summary:

​Cardiac ischemia may present atypically​.​

​Although some signs and symptoms are LESS predictive of ischemia, patients can have these symptoms and STILL BE experiencing ischemia.  Only with investigations in-hospital can cardiac ischemia truly be ruled-out.​​

​The role of the paramedic in the prehospital environment is to take all factors into account to search for suspected cardiac ischemia, not to rule it out .

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