Chest pain can indicate a range of conditions related to the heart, lungs or rib cage. For first aid providers, the most critical is the risk of a heart attack. A heart attack is usually caused by a blockage in one of the blood vessels supplying the heart muscle, resulting in damage to the heart. Prompt recognition and management of a heart attack can save lives. Delayed treatment increases the probability of complications such as sudden death or later heart failure. Other common causes of chest pain include angina and indigestion.
Guidelines
- While waiting for EMS to arrive, consider having the person suspected of having a heart attack take an oral dose of 150–300 mg acetylsalicylic acid. Acetylsalicylic acid should be avoided if the person is allergic to it, or if the person takes acetylsalicylic acid regularly and has just taken the recommended dose. *
- If the first aid provider is trained and oxygen is available, the provider may give oxygen to a person experiencing chest pain if they recognise the person as hypoxic.*
Good practice point
- If a heart attack is suspected, emergency medical services (EMS) should be accessed immediately. Urgent access is necessary if the pain is intense, the person has shortness of breath, the person’s skin is pale or ashen and clammy, or they have a bluish colour to the skin on their lips, ears, fingers or toes. Access EMS even if the pain has only lasted a couple of minutes.
- The first aid provider should help the person get into a comfortable position; the person should refrain from physical activity.
- If the person has medication, is diagnosed with angina and showing signs of acute chest pain, the first aid provider should assist them to take their medication.
- If EMS is delayed, a bystander may get an automated external defibrillator and keep it close to the person in case it is needed.
Chain of survival behaviours
Prevent and prepare
- There are national and global organisations that research how to reduce the likelihood of heart conditions. Refer to your country’s health authority for more information.
- Exercise and a healthy diet, combined with low or no alcohol consumption and not smoking, can help to reduce the chances of a heart attack.
- If you have family, friends or colleagues who have angina, be aware of where they keep their medication in case of an emergency.
- Keep acetylsalicylic acid on hand if you are diagnosed with coronary artery disease.
Early recognition
Ask the person about their chest pain. If they have been diagnosed with angina or other heart condition, they should be able to tell you this. Likewise, if the person has a history of indigestion, they may describe this to you. If the chest pain continues even after taking medication, it is important to quickly recognise the possibility of a heart attack and access EMS.
Signs and symptoms that may indicate someone is having a heart attack include:
- chest pain
- chest pain in combination with pain in the arm or shoulder
- chest pain in combination with sweating
- chest pain in combination with palpitations.
Pain may be described as discomfort, vice-like pressure, cramping, squeezing, burning. A heart attack can start with non-specific complaints especially in females:
- nausea
- shortness of breath
- pain radiating to the jaw
- pain in the upper abdomen
- pain between the shoulder blades
- pain that lasts more than a few minutes or it may come and go.
People may also experience the following signs and symptoms.
- paleness
- anxiousness
- bluish colour to the skin on their lips, ears, or fingers.
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NOTE
- The suspicion of a heart attack is supported if the person is known to have coronary artery disease. However, if in any doubt, assume it could be a heart attack.
- Heart attack symptoms may include any of the above but might be less noticeable in some populations such as people who are female, elderly or have diabetes.
- For angina, the pain is often familiar and improves when the person rests. For heart attack, the pain is persistent and emergency help must be accessed.
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First aid steps
- Help the person to sit down in a comfortable position and take their medication.
- Access EMS immediately if you suspect a heart attack. Ask a bystander to bring a defibrillator if possible.
- Suggest the person considers chewing a dose of acetylsalicylic acid if a heart attack is suspected.
- Reassure the person and monitor their breathing and responsiveness.
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NOTE
- If the person becomes Unresponsive with abnormal breathing, start CPR.
- Do not give acetylsalicylic acid to the person if they are allergic to it, have a bleeding disorder, or have already taken the recommended dose.
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Access help
- Ask bystanders to help you access EMS, monitor the person and get medication or a defibrillator.
- Emphasise that you suspect it is a heart attack when you access EMS so they can appropriately prioritise your case. Also update EMS if the person’s condition changes (e.g., they collapse and stop breathing).
- It is important to access help quickly to minimise any damage to the heart.
- If the person has been diagnosed with angina and has their medication, it may not be necessary to access EMS. However, you should access EMS if the pain does not subside as it usually does within a few minutes of taking medication.
- If the person has taken medication for indigestion but the pain does not subside, access EMS. Note that a heart attack is often mistaken for indigestion.
Recovery
- If angina pain patterns have changed, a change in medication or treatment may be needed. Suggest that the person seeks medical care.
Education considerations
Context considerations
- In places with ambulances, EMS can provide treatment during transport to the hospital, which can improve the person’s outcomes (Cartledge et al., 2017).
- Be aware of the recommended medications available in your country, for example, glyceryl trinitrate for angina or acetylsalicylic acid for a heart attack. Additionally, be aware of the laws surrounding whether a first aid provider can assist with or administer medication.
- In contexts where vasodilators (e.g. nitrates) are used, be aware that they might have side effects, including low blood pressure or unresponsiveness. Therefore, if EMS can quickly arrive, take their advice on whether to assist the person to take this type of medication.
- Consider focussing on the prevention aspect of the Chain of survival behaviours in all contexts and particularly where there is limited or no access to EMS. Awareness of how diet (including alcohol consumption), lack of physical activity and smoking contribute to increased risk should be included as part of first aid education on this topic.
Learner considerations
- Consider which part of the Chain of survival behaviours learners might focus on in this topic according to their circumstances. For example, for younger learners, it might be most appropriate to focus on prevention; while caregivers could focus on recognition.
- When working with a diverse group of learners, be sure to emphasise that symptoms may be less noticeable in females, older adults, and people with diabetes.
- When developing first aid programmes, research which different ‘at risk’ communities might be best targeted with education. For example, particular ethnic groups or more socially disadvantaged groups might be at higher risk of heart attack and other cardiovascular diseases due to health inequalities and lack of access to health services (Mendis et al., 2011; WHO 2011).
Facilitation tips
- Emphasise the need to recognise a heart attack and get help quickly.
- Raise awareness of risks associated with concealing pain at the early stages of a suspected heart problem by exploring the potentially serious causes and outcomes of chest pain.
- Explore how people may describe or feel different types of chest pain.
- Clarify any unfamiliar terminology. If necessary, resolve any confusion by differentiating between a heart attack and cardiac arrest.
- Identify the causes of chest pain but emphasise that the aim is not to diagnose the cause. It can be very difficult to tell what type of chest pain a person is experiencing, even for medical professionals. If the first aid provider is unsure, they should access EMS immediately.
- Ask learners to share their experiences with heart attacks and to describe what they did or would have done differently. This can be especially useful to explore key messages such as recognising a heart attack and not delaying access to EMS.
- Emphasise that sitting in a comfortable position eases the strain on the heart, and if the person collapses, they are less likely to injure themselves.
- Explain the reason acetylsalicylic acid can be beneficial is that acetylsalicylic acid makes the clot-forming part of blood less sticky and may improve blood flow past the blockage in the blood vessel.
- Include information about the possible contraindication for giving acetylsalicylic acid in some people (allergy or bleeding disorder).
Facilitation tools
- Use case studies relevant to learners’ contexts. The discussions from these studies can be adapted to create practice scenarios.
- Casualty simulation provides an opportunity for learners to practise communicating with someone who is in pain, ensuring the person is in a comfortable position, accessing EMS and being prepared to provide care should the person become unresponsive or stop breathing.
- The following materials may be helpful introductions to the topic:
> Signs and symptoms
> Heart attack video
Learning connections
- A heart attack may cause a person to stop breathing. Make the connections between this topic and how to help someone Unresponsive with abnormal breathing, including how and when to use a defibrillator.
- A heart attack can be a very frightening experience. Help learners make connections to any psychosocial support skills they can use to provide comfort.
- Encourage learners to think critically about how to position a person depending on their injury or illness. See General approach.
Scientific foundation
Systematic reviews
In 2019, the Centre for Evidence-Based Practice (CEBaP) completed a review on the following topics: clinical signs and symptoms of chest myocardial infarction (heart attack), and body positions for someone having a heart attack. In addition, we used a Cochrane systematic review on oxygen therapy for acute myocardial infarction and an International Committee on Resuscitation (ILCOR) systematic review about the use of acetylsalicylic acid.
Signs and symptoms
There is limited evidence from four systematic reviews of diagnostic accuracy studies showing that pain in both arms and a change in pain pattern over the last 24 hours may be predictive symptoms for the presence of acute myocardial infarction. Positional pain, pleuritic pain, sharp pain and/or palpitations could be considered as clinically helpful for the absence of acute myocardial infarction.
For people with chest pain, pain in the right arm, sweating and palpitations may be predictive symptoms for the presence of acute myocardial infarction. For people with various symptoms (e.g. symptoms of acute myocardial infarction, or suspected coronary artery syndrome) the evidence is not consistent and pain in right arm or shoulder and sweating may or may not be clinically helpful.
The following symptoms could not be considered clinically helpful to diagnose acute myocardial infarction:
- pain in the left arm, shoulder, neck, jaw or back
- central or right-sided chest pain
- sudden onset of pain
- substernal pain
- epigastric pain
- visceral pain
- aching
- oppressive, severe, burning or stabbing pain
- pain that lasts longer than 60 minutes
- time since onset of pain > 6 hours
- worsening pain after exertion
- associated syncope (unresponsiveness)
- nausea or vomiting
- shortness of breath
Evidence is of low certainty.
Body position
There is limited evidence from one experimental study neither in favour of passive straight leg raising (60°) nor lying flat on the back. In a randomised controlled trial with 18 anesthetised patients undergoing myocardial revascularization , a statistically significant difference in cardiac index between passive straight leg raising and lying flat on the back could not be demonstrated. However, this study also showed that passive straight leg raising resulted in a statistically significant (but not clinically meaningful) reduced right ventricular function (a marker of the cardiac fraction).
There is limited evidence from one observational study in favour of lying flat on the back. It was shown in a case-control study with people that had a history of heart attack that lying on the back resulted in a statistically significant increased cardiac index, compared to the lying facing chest down. However, a statistically significant difference in ejection fraction [function], when lying on the back compared to lying facing chest down, could not be demonstrated.
Evidence is of low to very low quality and results cannot be considered precise due to limited sample size and lack of data.
Oxygen therapy
A Cochrane systematic review on oxygen use in people with a heart attack identified evidence from five randomised controlled trials that compared people who had a suspected or proven heart attack and were given inhaled oxygen to a similar group of people given air (evidence is current to June 2016) (Cabello et al., 2016). These trials involved a total of 1,173 participants, 32 of whom died. Death rates were similar in both groups (very low-certainty evidence). Regarding pain, there was no effect for oxygen on pain relief when pain was directly measured nor when trials measured opiate use as a surrogate for pain (low-certainty evidence). With regard to complications following a heart attack, there was no clear effect for oxygen on a range of complications in the oxygen group compared to the air group (low-certainty evidence). Together, there is no evidence to support the routine use of inhaled oxygen in people with a heart attack, and we cannot rule out a harmful effect.
Acetylsalicylic acid
The ILCOR systematic review on first aid administration of acetylsalicylic acid (aspirin) for chest pain identified two observational studies and one randomised controlled trial that compared early (prehospital phase or within two hours from onset of chest pain) to late (more than two hours from onset of chest pain or in-hospital) administration of acetylsalicylic acid (Singletary, 2020).
Very low-certainty evidence was identified from two observational studies showing improved survival (at seven days and 30 days) with the prehospital early administration of acetylsalicylic acid (median 1.6 hours from pain onset) compared to late administration of acetylsalicylic acid (median 3.5 hours from pain onset, given at hospital admission). One of these studies also showed an improvement in survival at one year (very low-certainty evidence). Very low-certainty evidence was identified from two observational studies showing no significant difference in the incidence of complications, but they report inconsistent results about the incidence of cardiac arrest. Low-certainty evidence from one randomised controlled trial showed no benefit from giving enteric-coated acetylsalicylic acid within two hours of the onset of symptoms versus 3 to 24 hours after symptom onset on survival at 35 days. Very low-certainty evidence from two observational studies showed conflicting results: one of them showed a reduction in the incidence of asystole and the need for resuscitation wit early (compared to late) administration, whereas the other study showed a higher incidence of ventricular tachycardia and fibrillation. Studies evaluating the timing of acetylsalicylic acid administration on cardiac functional outcome, infarct size and/or chest pain resolution could not be found.
Non-systematic reviews
European Society of Cardiology Guidelines
The 2017 European Society of Cardiology Guidelines for the management of acute myocardial infarction in people presenting with a heart attack state the following:
- confirms the early use of acetylsalicylic acid
- underlines giving oxygen only to hypoxic people (oxygen is indicated in people with hypoxaemia: SaO2 < 90%)
- does not mention giving sublingual nitroglycerine routinely and lists contraindications beyond the learning requirements for first aid providers. (Ibanez, 2018.)
Use of EMS
A 2002 study examined the use of EMS in the United States and ascertained the factors that may influence its use by people with acute chest pain. Only half of the people with chest pain were transported to the hospital by ambulance, and these people had greater and significantly faster receipt of initial reperfusion therapies. People who didn’t use the EMS were on average younger, male, and at relatively lower risk on presentation. Wider use of EMS by people with a suspected heart attack may offer considerable opportunity for improvement in public health (Canto et al, 2002).
Education reviews
Two papers provided insights about the education needed to help first aid providers recognise and act effectively when they witness acute chest pain.
National Heart Foundation “Warning Signs of Heart Attack” campaign
Cartledge et al. (2017) explored how awareness from a campaign about the barriers of calling EMS for acute coronary syndrome influenced people’s willingness to call. They found no association between having seen the campaign and calling EMS in a cohort of people with acute coronary syndrome. Barriers such as EMS response times or downplaying the seriousness of symptoms were still highly prevalent among the population of concern, despite the campaign’s targeted messages.
Though relatively small in quantitative terms, these findings point to cultural and social differences with regards to how people interpret and understand “symptom severity”, and whether they are eligible to access EMS. For example, they may question if they actually need medical assistance or believe that what they are experiencing is not severe enough to “burden” EMS. The study revealed a disconnect between what people saw in the campaign and how it related to them. For example, they may have seen a visual of someone experiencing a heart attack but not associate the signs and symptoms with themselves when they experience it. This disconnect has implications on whether people seek help and on the outcomes of their health. These educational considerations can be applied to Breathing difficulties as well.
Delayed hospital arrival
Brokalaki et al. (2011) undertook a two-year cross-sectional study among 477 heart attack patients in two large tertiary hospitals in Greece. They conducted structured face-to-face interviews. Information regarding peoples’ socio-demographic characteristics, medical history and factors that might correlate with delayed hospital arrival were collected. The main significant factor connected with delayed hospital arrival among heart attack patients was the absence of another person (such as a companion or attendant) during the heart attack (p = 0.049). This correlation highlights the importance of teaching informal and formal caregivers about the signs and symptoms of a heart attack and how to call for help immediately and provide first aid. The study reinforced the evidence that early hospital admission contributes significantly to the successful management of heart attack, therefore also supporting the value of teaching recognition and immediate action in cases of suspected heart attacks (as potentially indicated by chest pain).
References
Systematic reviews
Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016) Oxygen therapy for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12). DOI https://doi.org/10.1002/14651858.CD007160.pub4
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Myocardial infarction – Predictive symptoms. Available from https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Myocardial infarction – Posture. Available from https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J., Cassan, P., … Woodin, J.A. (2020). 2020 International Consensus on First Aid Science with Treatment Recommendations. Circulation, 142(16), S284–S334. DOI https://doi.org/10.1161/CIR.0000000000000897
Non-systematic reviews
Canto, J. G., Zalenski, R. J., Ornato, J. P., Rogers, W. J., Kiefe, C. I., Magid, D., … & Barron, H. V. (2002). Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2. Circulation, 106(24), 3018-3023.
Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., Marcassa, C., Quinn, T., van Weert, H., & Task Force on the management of chest pain. (2004). Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology, 5(4), 298–323.
Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., …& ESC Scientific Document Group (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal, 39(2), 119–177.
O’Connor, R. E., Al Ali, A. S., Brady, W. J., Ghaemmaghami, C. A., Menon, V., Welsford, M., & Shuster, M. (2015). Part 9: Acute coronary syndromes. Circulation, 132(18 suppl 2), S483–S500. Retrieved from https://www.ahajournals.org/doi/full/10.1161/cir.0000000000000263
Education references
Brokalaki, H., Giakoumidakis, K., Fotos, N. V., Galanis, P., Patelarou, E., Siamaga, E., & Elefsiniotis, I. S. (2011). Factors associated with delayed hospital arrival among patients with acute myocardial infarction: a cross‐sectional study in Greece. International nursing review, 58(4), 470–476. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1466-7657.2011.00914.x
Cartledge, S., Finn, J., Straney, L., Ngu, P., Stub, D., Patsamanis, H., … & Bray, J. (2017). The barriers associated with emergency medical service use for acute coronary syndrome: the awareness and influence of an Australian public mass media campaign. Emergency Medicine Journal, 34(7), 466–471. Retrieved from https://emj.bmj.com/content/34/7/466.abstract
Mendis, S., Puska, P., Norrving, B., & World Health Organization. (2011). Global atlas on cardiovascular disease prevention and control. World Health Organization.
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