What are the key questions to ask a patient suspected of having a myocardial infarction (heart attack)?

Critical Questions for Suspected Myocardial Infarction

When evaluating a patient with suspected myocardial infarction, immediately ask about chest pain characteristics, duration of symptoms, associated symptoms (shortness of breath, diaphoresis, nausea), and aspirin allergy status—these answers directly determine whether to activate emergency protocols and initiate time-sensitive reperfusion therapy. 1

Immediate Symptom Assessment

Primary Symptom Inquiry

• Ask about chest discomfort characteristics: location, quality (pressure, tightness, squeezing), radiation to arm/neck/jaw, and severity 1, 2
• Determine symptom duration: symptoms lasting >20 minutes at rest indicate high-risk ACS requiring immediate ED referral 1
• Inquire about epigastric pain or indigestion: these are recognized manifestations of acute MI and should trigger immediate ECG 3
• Note that chest pain may be absent: 43% of women with acute MI do not experience chest pain, making other symptoms critical 4

Associated Symptoms to Elicit

• Shortness of breath: present in 57.9% of women during acute MI and 42.1% as a prodromal symptom 4
• Diaphoresis (sweating): a classic associated symptom of myocardial ischemia 2
• Nausea and vomiting: significantly more common in women (53.8% vs 29.5% in men) 5
• Unusual fatigue or weakness: reported by 70.7% of women as a prodromal symptom and 54.8% during acute MI 4
• Palpitations, dizziness, or syncope: particularly important in women, who experience these at higher rates 5
• Back pain: occurs in 42.3% of women versus 14.5% of men with first MI 5

Time-Critical Information

Symptom Onset and Progression

• Establish exact time of symptom onset: reperfusion therapy must be initiated within 12 hours, with maximum benefit in the first hour ("golden hour") 3
• Ask if symptoms are worsening or unimproved after 5 minutes: patients should call 9-1-1 if symptoms persist beyond 5 minutes 1
• Inquire about prodromal symptoms: 95% of women report symptoms more than 1 month before AMI, including unusual fatigue, sleep disturbance, and shortness of breath 4

Response to Interventions

• Ask if patient has taken nitroglycerin: determine if symptoms responded to NTG, though lack of response does not rule out ACS 1
• Determine if aspirin was already taken: critical for deciding immediate aspirin administration 1

Risk Stratification Questions

High-Risk Features

• Hemodynamic instability: ask about lightheadedness, syncope, or presyncope 1
• Recent syncope or presyncope: indicates need for immediate ED referral 1
• Symptoms at rest versus exertion: rest symptoms suggest unstable angina or acute MI 1

Medical History

• Known coronary artery disease: prior MI, PCI, or CABG 1
• Cardiovascular risk factors: diabetes, hypertension, peripheral vascular disease 1
• Aspirin allergy history: determines whether to advise immediate aspirin administration 1
• Recent procedures: PCI or CABG within past weeks (Types 4a, 4b, 5 MI) 1

Medication and Allergy History

Critical Medication Questions

• Current antiplatelet therapy: aspirin, clopidogrel, or other P2Y12 inhibitors 6
• Nitroglycerin availability and tolerance: determines prehospital management 1
• Contraindications to aspirin: allergy or active bleeding 1
• Recent thrombolytic therapy: if within 2-3 hours, avoid immediate catheterization due to bleeding risk 3

Gender-Specific Considerations

Women's Atypical Presentations

• Specifically ask women about unusual fatigue: present in 70.7% as prodromal symptom and 42.9% during acute MI 4
• Inquire about sleep disturbances: reported by 47.8% of women before MI 4
• Ask about multiple concurrent symptoms: women report an average of 7.3 acute symptoms versus men's typical presentation 4, 5
• Note that only 29.7% of women report chest discomfort as a prodromal symptom, compared to the hallmark presentation in men 4

Common Pitfalls to Avoid

• Do not dismiss atypical symptoms, especially in women, elderly, or diabetic patients who may present without chest pain 4, 5
• Do not delay evaluation for patients who respond to nitroglycerin: response to NTG does not exclude ACS 1
• Do not perform telephone-only assessment: evaluation cannot be performed solely over the phone for suspected ACS 1
• Do not wait for cardiac biomarkers before initiating treatment: ECG findings alone warrant immediate reperfusion in ST-elevation or new LBBB 3
• Do not underestimate prodromal symptoms: 95% of women report warning symptoms that may predict acute events 4