Synopsis
Separate immediately dangerous chest-pain causes from lower-risk explanations, interpret ECG and troponin within their limitations, and start the appropriate urgent pathway without diagnostic anchoring.
- Assess circulation, respiratory compromise and ongoing pain before applying a low-risk chest-pain pathway.
- Obtain an early twelve-lead ECG; a normal initial tracing does not exclude acute coronary syndrome.
- Use serial ECGs and the locally validated high-sensitivity troponin pathway when the diagnosis remains uncertain.
Key red flags
Abrupt severe chest or back pain with syncope, pulse asymmetry or a neurological deficit requires urgent assessment for acute aortic disease.
Investigation priorities
Identify coronary occlusion, dynamic ischaemia and rhythm disturbances.
Management branches
The presentation and ECG support ACS, particularly an acute coronary occlusion requiring reperfusion.
- Monitor rhythm and pressure, obtain IV access, give indicated aspirin and analgesia, and provide oxygen only when hypoxaemia or other immediate critical illness warrants it.
- Activate the appropriate urgent coronary pathway for the ECG and clinical situation; do not wait for a troponin result when an established emergency reperfusion indication is present.
The patient is currently stable and the first ECG or troponin is nondiagnostic.
Key medicines
Aspirin loading for suspected acute coronary syndromeGive a single 300 mg oral loading dose as soon as possible for suspected ACS unless there is clear aspirin allergy or another relevant contraindication; document any prehospital dose before administering.Assess active bleeding and major alternative diagnoses such as suspected aortic dissection. Further antithrombotic choices depend on the confirmed pathway, bleeding risk and planned intervention.