Is chest pain that improves still considered a potential cardiac issue requiring Advanced Life Support (ALS) resources?

Your Colleague is Wrong: Chest Pain That Improves Still Requires Advanced Life Support

You are absolutely correct—chest pain that improves does NOT rule out a cardiac emergency and Advanced Life Support resources should NOT be cancelled based on symptom improvement alone. This is a dangerous misconception that can lead to preventable deaths.

Why Symptom Improvement is Unreliable and Dangerous

The Critical Evidence Against Cancelling ALS

• Approximately 1 in every 300 patients with chest pain transported by private vehicle (without ALS capability) goes into cardiac arrest en route to the hospital 1. This stark statistic demonstrates that seemingly stable chest pain patients can deteriorate catastrophically without warning.

• Emergency medical technicians and paramedics can provide life-saving interventions (e.g., early cardiopulmonary resuscitation and defibrillation) if the patient develops cardiac arrest 1. Without ALS resources, these interventions are unavailable when sudden deterioration occurs.

• All patients presenting with chest discomfort or other symptoms suggestive of MI or unstable angina should be considered high-priority triage cases 1. The guidelines make no exception for patients whose symptoms have improved.

The Guideline-Mandated Approach to Chest Pain

The American College of Cardiology and American Heart Association explicitly state that patients should be placed on a cardiac monitor immediately, with emergency resuscitation equipment, including a defibrillator, nearby 1. This requirement exists regardless of whether symptoms have improved.

For patients with chest pain or acute dyspnea of suspected cardiac origin, systems providing advanced life support may reduce delays in diagnosis and administration of appropriate treatment and subsequently improve outcome 1.

The Nitroglycerin Fallacy

Your colleague may be confusing symptom improvement with diagnostic certainty. However:

• Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion 1. Even if a patient's chest pain improves spontaneously or with nitroglycerin, this does NOT exclude acute coronary syndrome.

• The American Heart Association guidelines recommend calling 9-1-1 for chest pain that is unimproved or worsening after 5 minutes, but for patients with chronic stable angina whose symptoms significantly improve after one nitroglycerin dose, they should still call 9-1-1 if symptoms have not totally resolved after 3 doses 1. Note that even partial improvement warrants continued monitoring and transport.

The Real-World Clinical Algorithm

What Should Happen in the Field:

1. Any patient with chest pain of potential cardiac origin requires cardiac monitoring and immediate access to defibrillation capability 1

2. ALS resources should remain on scene to provide:

   • Continuous cardiac monitoring 1
   • Immediate defibrillation capability if cardiac arrest occurs 1
   • Pre-hospital ECG acquisition (associated with shorter reperfusion times and lower mortality) 2
   • Advanced airway management if needed 1
   • Medication administration (epinephrine, amiodarone, morphine, nitroglycerin) 1

3. Transport should occur with ALS capability regardless of symptom improvement 1, 2

Common Pitfalls to Avoid

The most dangerous pitfall is assuming that symptom improvement equals diagnostic certainty. Acute coronary syndrome can present with waxing and waning symptoms, and patients can appear stable immediately before sudden cardiac arrest 1.

Another critical error is relying on response to nitroglycerin as a diagnostic test. Multiple guidelines explicitly warn against this practice 1.

Cancelling ALS resources based on clinical appearance alone ignores the unpredictable nature of cardiac emergencies. Even patients who appear stable can deteriorate suddenly, and the presence of ALS resources is the difference between survival and death in these cases 1, 2.

The Bottom Line for Your Colleague

Morbidity and mortality from acute coronary syndrome can be reduced significantly if patients are transported by ambulance with ALS capability rather than by friends, relatives, or BLS-only units 1. The evidence is unequivocal: patients transported by EMS have shorter time to treatment and better outcomes 2.

In situations such as chest pain, systems providing advanced life support may reduce delays in diagnosis and administration of appropriate treatment and subsequently improve outcome 1. Your colleague's practice of cancelling ALS resources contradicts established guidelines and places patients at unnecessary risk of preventable death.