In my six years as a paramedic in metropolitan Sydney, I’ve been called to numerous cases of chest pain. Sometimes, it is a heart attack; often, it is something else. But for my patients, it can be quite a scary experience nonetheless.
What would you do if you had sudden onset chest pain? Would you wait, hoping it would go away, or would you call 000? This is something a lot of my patients consider when they get sudden chest pain, especially if they've never felt something like it before. They don't want to bother us because they think there are more important jobs to attend to.
But when it comes to your heart, you don't want to stall. You've only got one, and you don't want it to stop working – it keeps the rest of your body going.
Signs and symptoms of heart attack
A heart attack occurs when the heart is deprived of oxygen due to a blockage in one of the coronary arteries that supplies blood to the heart. These blockages can be the result of build-up of plaque, either stable or unstable.
For men, the typical signs and symptoms of a heart attack include sudden onset left-sided chest pain that can radiate into the left side of the neck, jaw and arm. It can also radiate into the back. Many will describe the pain as strong, heavy pressure, like an elephant sitting on the chest or sharp constant pain. Whatever it is, it can be quite uncomfortable!
Women often experience atypical symptoms, such as generally feeling unwell, nausea, dizziness, shortness of breath, or become quite pale and diaphoretic (sweaty). These atypical symptoms may or may not occur with the typical symptoms of pain.
In one case I was called to, a woman in her late 60s hadn't been feeling well since the morning. She had slight nausea but no vomiting, a bit of dizziness, and generally felt weak and 'not quite right'. She had taken some pain relief and waited several hours to call us because she thought the feeling would go away. When we arrived, we assessed her and found she met all indications of a heart attack. We took her straight to hospital, where she had immediate surgery to clear the blockage in her coronary artery.
What happens when you call 000?
When you call 000 and tell the operator that you are having chest pain, it will be taken quite seriously. They will send the nearest available ambulance to you – lights and sirens.
It doesn’t matter how old you are, your ethnicity, your socio-economic status or your location. We will try to get to you as soon as possible.
The operator will tell you to take 300mg of aspirin, if available. Aspirin is an anticoagulant and will help break down any blood clots, which may be potentially the cause of your chest pain. Don't worry if you don't have it available. The attending paramedics will give you some when they arrive, especially if they determine that you have having what we call acute coronary syndrome.
What can you do after calling an ambulance?
After you've made the call, just try to relax. The operator will advise you not to eat or drink anything apart from the aspirin. If you have taken it, remember to tell the attending paramedics that you have and at what time you took it.
Get your things ready to go to hospital, such as your keys, purse/wallet, phone and charger, and any regular medications that you take. You might like to take a change of clothes and toiletries, but please don't over-exert yourself. If there is someone else with you who is healthy and well enough, please get them to gather these things for you and ask them to escort the paramedics to you once they arrive.
When the paramedics arrive
Once the ambulance arrives, there are a few things going through our minds as to what your issue could be, such as other possible conditions causing chest pain. As we walk towards your location, we are surveying the area for obstacles or stairs. So don't be frustrated if it looks like we are taking our time to get to you. We are actually trying to work out the best and most efficient way to get you out of your current location and to the ambulance, to minimise the chances of you exerting yourself and putting more stress on your heart. We also have to work out if we need extra paramedics to come help us.
Once we get to you, we will assess you for your vital signs, such as blood pressure, oxygen saturations, heart rate and blood sugar levels. We will also conduct an electrocardiograph (ECG) to see what your heart is doing. The majority of the time, in addition to aspirin, we may give you pain relief or fluids to maintain your blood pressure intravenously.
If your ECG or vital signs show other things that need to be treated, we will also look at that. Depending on your attending paramedics, we may do all this prior to going to the ambulance or while en route. It all depends on how your symptoms present and how quickly we can get you safely to the ambulance.
For all chest pain cases, we recommend transport to hospital to obtain a blood test, as the only way to definitively determine if you are having a heart attack is to check the levels of a particular enzyme, troponin, in your blood. An ECG can only tell us so much.
Assessing you for acute coronary syndrome
Acute coronary syndrome (ACS) encompasses signs and symptoms that typically indicate a person is having some sort of cardiac event. These can range from those for a STEMI (ST-elevation myocardial infarction), where a segment of the ECG is elevated compared to normal, to a non-STEMI, where the segment is not elevated. However, both refer to a potential heart attack, which can only be confirmed by elevated troponin levels. Chest pain that is neither is called angina.
An ECG can sometimes pick up a STEMI. If it does, the paramedic will transmit this to the nearest cardiac laboratory. The cardiologist will call back and direct them to either go to a hospital’s Emergency Department (ED) or straight to its Catheter Laboratory, if the patient needs to have a clot removed immediately. If the cardiologist is not convinced it is a STEMI or if the ECG shows something else, the paramedic can usually tell if something isn't quite right. Either way, we treat the majority of chest pains as ACS and recommend further assessment at ED, unless there are other signs and symptoms that suggest otherwise.
Once you get to the ED, you will be triaged and the nurses will perform their own ECG. They will take some blood for tests, and the doctors will determine from there what may be going on. Approximately four hours later, they will do another blood test and determine any changes to your troponin levels.
What can cause a heart attack?
There is a strong correlation between high cholesterol levels and high blood pressure with an increased chance of poor heart health. Having high cholesterol may lead to a blood clot, which may then lead to a heart attack.
There is also a strong correlation with family history as well as ethnicity. As you get older, it is a very good idea to have regular check-ups with your GP and keep an eye on your heart and any potential blockages in your arteries. The majority of my patients who present with chest pain are 45 years old and above.
It is not as common, but unexpected stress on the heart can also cause a heart attack. Several years ago, I was called to a man in his mid-30s who was complaining of chest pain. We treated him for ACS and took him to the nearest ED. Prior to his chest pain, he had just finished an ice coffee drink that contained four to five shots of espresso, sending his troponin levels through the roof. His heart simply couldn't take it. He was admitted and treated, and several days later was discharged, recovered.
Other conditions that may cause chest pain
How do you know it's not a heart attack? The simple answer is: you don't, except with a blood test to check your troponin level.
Many of the chest pain cases I have attended over the years can be attributed to panic attacks, respiratory issues, really bad cases of reflux, muscular strains, irregular heart rates (arrhythmias) or other cardiac issues such as pericarditis (infection of the tissue that surrounds the heart). That's why the attending paramedics will assess you using our machines and also ask you lots of questions about the events leading up to your call and what sort of symptoms you might have experienced along the way.
It is not always a black-and-white picture, so it is vital that you call 000 if you experience chest pain or other signs or symptoms of heart attack. If you have any concerns about your health, always speak to your healthcare professional.
About the author
Maggie Chung
Maggie has been a paramedic with NSW Ambulance since 2015, working mainly in the Western Sydney and Blue Mountains areas. She has degrees in Paramedic Practice and Science (Psychology). She is passionate about health education and training and also runs her own first aid training courses with a first aid course specially designed for parents and carers. Maggie also has a passion for pain management and yoga therapy, human movement and biomechanics, enhanced by a Diploma in Sports Kinesiology and over 15 years of yoga teaching. She is currently working towards tertiary qualifications in Physiotherapy.