Synopsis
Build a time-critical, discriminating cardiovascular history that identifies instability, separates likely mechanisms and directs the next test.
- Characterise every symptom by onset, provoking and relieving factors, quality, site or radiation, duration, associated features and trajectory.
- Typical angina has three features: constricting chest or neck, shoulder, jaw or arm discomfort; provocation by exertion; and relief by rest or glyceryl trinitrate within about 5 minutes.
- Do not use response to glyceryl trinitrate alone to diagnose cardiac pain; oesophageal pain may also improve.
Key red flags
New or worsening pressure, heaviness or tightness, especially at rest or with autonomic symptoms, breathlessness or radiation; painless presentations occur, particularly with diabetes or older age.
Investigation priorities
Identify ischaemia, infarction, conduction disease, pre-excitation, QT abnormality or arrhythmia.
Management branches
Current or recent symptoms compatible with ACS
- Perform ABCDE, observations and a 12-lead ECG without waiting for blood results.
- Give aspirin when ACS is suspected unless contraindicated, and follow the STEMI or NSTE-ACS route according to ECG and instability.
Symptoms are stable and there is no acute high-risk feature