A fictional 61-year-old develops central chest pressure with sweating and nausea while walking to work.
Frame the danger first.
- Treat suspected acute coronary syndrome as time-sensitive while considering other lethal causes of chest pain.
- A normal first ECG does not by itself exclude acute coronary syndrome.
- Interpret symptoms, ECG findings, haemodynamics and biomarkers together.
Act, escalate, reassess.
- Perform immediate clinical assessment, observations and a 12-lead ECG using the local chest-pain pathway.
- Escalate haemodynamic instability, ongoing pain or diagnostic ECG changes urgently.
- Use current local/NICE antiplatelet, anticoagulation and reperfusion pathways; check contraindications.
- Repeat assessment and ECGs if symptoms continue or evolve.
Red flags that change pace.
- Shock, malignant arrhythmia, acute heart failure or ongoing severe pain
- Diagnostic ST-segment elevation or dynamic ischaemic change
- Features suggesting aortic syndrome, pulmonary embolism or tension pneumothorax
What makes care less safe.
- Reassurance from a single normal ECG or initial biomarker
- Giving protocol treatment without checking bleeding risk or alternative diagnoses
- Failure to document symptom timing and dynamic change
Say the concern plainly.
This is suspected ACS with symptoms beginning at [time]. The patient is [stable/unstable]; ECG shows [finding] and serial change is [present/absent]. I need urgent review for the appropriate invasive or reperfusion pathway.