2010 American Heart Association

more common in women, the elderly, and diabetic patients.
21–23 The physical examination of the patient with ACS
is often normal.
Public education campaigns increase patient awareness and
knowledge of the symptoms of ACS, yet have only transient
effects on time to presentation. 24,25 For patients at risk for
ACS (and for their families), primary care physicians and
other healthcare providers should consider discussing the
appropriate use of aspirin and activation of EMS system.
Furthermore, an awareness of the location of the nearest
hospital that offers 24-hour emergency cardiovascular care
can also be included in this discussion. Previous guidelines
have recommended that the patient, family member, or
companion activate the EMS system rather than call their
physician or drive to the hospital if chest discomfort is
unimproved or worsening 5 minutes after taking 1 nitroglycerin
treatment. 2
Initial EMS Care (Figure 1, Box 2)
Half the patients who die of ACS do so before reaching the
hospital. VF or pulseless VT is the precipitating cardiac arrest
rhythm in most of these deaths, 26,27 and it is most likely to
develop in the early phase of ACS evolution. 28 Communities
should develop programs to respond to cardiac emergencies
that include the prompt recognition of ACS symptoms by
O’Connor et al Part 10: Acute Coronary Syndromes S789
Figure 2. Prehospital fibrinolytic checklist.
Adapted from Antman EM, et al.
ACC/AHA guidelines for the management
of patients with ST-elevation myocardial
infarction: a report of the American
College of Cardiology/American
Heart Association Task Force on Practice
Guidelines (Committee to Revise the
1999 Guidelines for the Management of
Patients with Acute Myocardial Infarction).
Circulation. 2004;110:e82-e292, with permission
from Lippincott Williams & Wilkins.
Copyright 2004, American Heart
Association.
patients and their companions as well as by healthcare and
public safety providers and early activation of the EMS
system. Additional features of such a program include highquality
CPR for patients in cardiac arrest (see Part 5: “Adult
Basic Life Support”) and rapid access to and use of an
automated external defibrillator (AED) through community
AED programs (see Part 6: “Electrical Therapies”). 29 Emergency
dispatch center personnel should be educated in the
provision of CPR instructions for lay rescuers before the
arrival of EMS. EMS providers should be trained to respond
to cardiovascular emergencies, including ACS and its acute
complications.
Emergency dispatch center personnel can provide instrutctions
to the patient or caller before EMS arrival. Because
aspirin should be administered as soon as possible after
symptom onset to patients with suspected ACS, it is
reasonable for EMS dispatchers to instruct patients with no
history of aspirin allergy and without signs of active or
recent gastrointestinal bleeding to chew an aspirin (160 to
325 mg) while awaiting the arrival of EMS providers
(Class IIa, LOE C). 30–35
EMS providers should be familiar with the presentation of
ACS and trained to determine the time of symptom onset.
EMS providers should monitor vital signs and cardiac rhythm
and be prepared to provide CPR and defibrillation if needed.
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