Questionnaire/history:

Acute onset of central or band-like chest pain (CP)? Radiation to the jaw, arms, or back? Pain frequently with little/no exertion (abrupt deterioration of stable angina)? Nausea/vomiting? Sweating? Breathlessness? Haemodynamic instability (eg sytolic blood pressure < 90 mmHg)? (GTN not ot be used to confirm or exclude ACS)

Risk factors (older age, male, smoking, hypertension, diabetes, increase lipid leavels, family history of CVD)?

Investigations: ECG Troponin

Diagnosis: ST Elevation Myocardial Infarction (STEMI = new symptoms + ST elevation + positive troponin)?

Non ST Elevation Acute Coronary Syndrome (NSTE-ACS) - Unstable Angina (UA = new symptoms +/- ischaemic ECG + negative troponin)

- Non ST Elevation Myococardial Infarction (NSTEMI = new symptoms +/- ischaemic ECG + positive troponin) Management: While waiting for ambulance:

- Sat patient up?

- Offered oxygen as SpO2 < 94% (with face mask and flow rate to 5-10 L/min to achieve target SpO2 of 94-98% as not at risk of hypercapnic respiratory failure)?

- As chronic obstructive pulmonary disease with risk of hypercapnic respiratory failure, used 28% Venturi mask with flow rate at 4 L/min to achieve target SpO2 of 88-92%?

- As ACS suspected gave GTN and aspirin 300 mg (75 mg if alredy on aspirin) - Opioid (eg diamorphine IV 2.5-5 mg or morphine IV 5-10 mg over 5 minutes

- Monitored BP, pulse, SpO2 and repeated ECG?

- As acute pulmonary oedema suspected gave furosemide 40-80 mg slowly IV, metoclopramide 10 mg IV and GTN?

- As tension pneumothorax suspected and person's condition life threatening inserted large-bore cannula through 2nd ICS in the MCL on the side of the pneumothorax?

Emergency referral:

Suspected ACS +

current CP or complications (eg pulmonary oedema) or

pain-free, but have had CP in the last 12 hours and have and abnormal ECG or an ECG is not available or

recent history of ACS, who have developed further CT

Urgent same-day assessment:

Suspected ACS

+ pain-free with CP in the last 12 h + normal ECG + no complicatoins

pain-free with CP in the last 12-72 h anbd no complications

Assessment within 2 weeks:

Suspected ACS

+ pain-free with CP more than 72 h ago + no complications

(Urgency decided on the basis of ECG, high-sensitivity blood troponin and advice from cardiologist)

Suspected underlying malignancy (such as lung cancer)

A lung or lobar collapse or pleural effusion (if admission not required)

Routine assessment:

Suspected stable angina where diagnosis cannot be excluded in primary care (to consider aspirin 75 mg od)

CP with unclear cause Clear diagnosis for CP, but symptoms persist despite management in primary care

Troponin:

Traditional: confident result after 10-12 hours after onset of pain

High sensitivity troponin: single negative test > 2 h after onset of CP can rule out ACS, often sample at initial assessment followed by a 2nd sample at 30 minutes to 3 h (if appropriate)

Dual antiplatelet therapy (best done by secondary care):

STEMI for primary PCI: Aspirin + Prasugrel (given in catheter lab)

NSTEMI/UA with high risk of adverse events (GRACE score >3%): Aspirin + Prasugrel or Ticagrelor (often determined by time to PCI - Ticagrelor if delay)

NSTEMI/UA with low risk of adverse events (GRACE score <3%): Aspirin + Ticagrelor

High bleeding risk: Aspirin + Clopidogrel

Reference(s):

Hickam, D. A.: Chapter 9. Chest Pain or Discomfort, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. 1990

NICE CKS: Chest pain