Home Paramedicine/The Job Anginal Equivalents Part II

Anginal Equivalents Part II


A slight clarification from yesterday’s post.  Since “Angina Pectoris” literally mean pain in the chest, it is a symptom more than a condition. However, for our purposes, I’m using the term to indicate inadequate perfusion to the myocardium. Although when I write about painless Angina, it’s technically incorrect, it is more descriptive and thus better for my purposes in this post.

In my last post I stated that most patients experience chest pain or discomfort and dyspnea when having an Anginal episode. While being true, it is not a complete answer and the exceptions are where patients and paramedics often get themselves into trouble. While the so called classic symptoms are indeed chest pain and dyspnea, many patients have other symptoms. This is particularly so as we age and other medical problems complicate the process.

Elderly patients feel pain differently or in some cases don’t feel pain at all when they are having an Anginal episode. This is even more pronounced in patients with diabetes. Diabetes causes many changes to the body, none of them desirable. One of the changes is deterioration of the peripheral nervous system, part of which causes us to feel pain. Thus, people with Angina who are also Diabetics don’t always feel chest pain when they are having an Anginal episode. In fact, they often won’t feel any chest pain when having a heart attack either.

Add to this the fact that women of all ages don’t always have what we consider the classic symptoms of CAD. That just makes our job that much more difficult.

This makes it more difficult, although by no means impossible, to sort out what is happening with a patient who calls for an ambulance because of an Anginal episode, but does not have chest pain.

Because of a flaw in paramedic education students are taught that heart attacks and Angina present with “crushing mid sternal chest pain, often with radiation to the left jaw and arm”. While classically true, if you limit you thinking to those complaints you are going to miss an awful lot of patients with cardiac problems. Which is not good for the patient or your career as a paramedic. Paramedics are not alone in this. If you do an internet search for “Angina” you will find that just every article uses the words “chest pain” in the first sentence. Which makes sense if you take the words literally, but doesn’t help us to understand what happens during an Anginal episode.

Remember that the cause of the Angina is insufficient blood supply to the muscle of the heart. As with any other muscle, cutting off the supply of oxygenated blood will cause discomfort to the effected area as well as impair the organs ability to perform it’s intended function.

Which brings us to the title of these two posts. When a patient presents with atypical complaints accompanying their Anginal episodes we call those symptoms Anginal Equivalents. That just means that their Angina manifests itself in non typical ways. Most commonly, we will see dyspnea and fatigue as Anginal Equivalents. Sometimes we will see nausea with or without vomiting. Or diaphoresis (cold sweat). Or dizziness. In extreme cases the patient will pass out (syncope). Most of the time there is dyspnea with these symptoms, but not always.

As paramedics, it is incumbent upon us to look beyond what we are classically taught are the symptoms of Angina. As patients or relatives of patients, it’s also important to understand there are symptoms other than chest pain that can herald Angina.

It is also important not to be distracted by other medical conditions that the patient may have. Unless the patient has a confirmed history of Chronic Obstructive Pulmonary Disease (COPD) or has other findings that suggest Pneumonia, a complaint of dyspnea should lead the paramedic to first think of CAD. Similarly, Hypoglycemia from Diabetes presents with changes in mental status and diaphoresis, but I’ve never heard of  chest discomfort or dyspnea being among the complaints.

As a friend of mine said recently while we were discussing this and how Anginal Equivalents and trick new paramedics,

Dyspnea + Weakness + History of Diabetes = Cardiac problem

As the family member of a person who has Diabetes and is it risk for CAD, what should you be looking for?

  • Chest Pain, of course.
  • Fatigue  while walking or doing other activities of daily living (ADL). Especially if this is new or has changed for the worse.
  • General weakness and inability to engage in ADL that your family member was formerly able to engage in.
  • Diaphoresis with Dyspnea when walking or engaging in ADL.
  • Dsypnea alone while engaging in ADL or walking. “Let me stop for a minute to catch my breath.”
  • Nausea or vomiting when combined with any of the above.
  • Dizziness when engaging in any of the above.

Interestingly, a paramedic should also look for any or all of these as well as asking the patient or family about a recent history of any of these.

It is very easy for the patient, patient’s family, or paramedic to attribute any or all of these symptoms to other, less dangerous situations. It’s an easy trap to fall into, but it’s a dangerous one for the patient.  Patient’s will often minimize or rationalize these episodes and they will go unexamined.

Like most things in medicine, or life in general for that matter, diagnosing the problem correctly is the hard part. Finding the origin of a medical problem makes treating the problem that much easier. In the case of Angina, the treatment is identical. Give the patient oxygen, start an IV, give the patient some NTG. If the patient gets better you have now confirmed your diagnosis. If they don’t, the chances are it was either not Angina or an Angina equivalent.

All of which I tried to impress upon my spareomedic partner du jour earlier this week. I don’t think he got it, but I hope that my readers do.

Finally, keep in mind that Angina is often progressive. Just because the patient’s Angina is stable this week, doesn’t mean that it won’t change next week or next month. So, always ask about changes in the pattern of your patient’s Angina. “What’s different about today’s episode that prompted you to call an ambulance?” Just remember to use an inquisitive, not accusatory tone of voice when asking that question. It’s all too easy for a patient to hear “You called an ambulance for this?” when that’s not what you meant at all.

Summing up both posts. Angina results from restriction of blood flow to the myocardium, usually from restriction on the Coronary Arteries. Classically this results in chest pain either with or without dyspnea. Many classes of patients don’t have the classic signs and symptoms we are taught to expect with Angina. The alert paramedic will look beyond the obvious to figure out what is really wrong with the patient. The alert paramedic will also not be distracted by the patient’s medical history, although history can certainly be helpful in diagnosis.

And finally, if you’re a young new medic don’t think that just because your cranky old partner hasn’t asked a lot of questions, hasn’t put a hand on the patient, and hasn’t listened to lung sounds, he doesn’t know what’s going on with the patient.  He figured it out five minutes ago and is already ten steps ahead of you planning out the course of treatment and to which hospital the patient is going to be transported.  He’s just waiting to see if you’ll figure it out anytime before the end of the shift.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.


  1. Yeah some times it is pretty hard to get through to dense people.

    How hard it is to assume that all chest pain is cardiac unless otherwise obvious or proven otherwise?

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