- Heavy, aching or tight
- Central chest or left sided
- Not related to respiration or movement
- May radiate to arms, neck, or jaw
- Radiation to both arms – Likely ACS
- Radiation to left arm – Likely ACS
- Nausea / Vomiting – Likely ACS
- SOB on exertion – Likely ACS
- Associated with Sweating – Likely ACS
- Hypotension – Likely ACS
- S3 – Likely ACS
- Describes as previous angina - Likely ACS
- Pleuritic/ Positional/ Sharp Pain – Unlikely ACS (not impossible)
- Tender on Palpation – Unlikely ACS (not impossible)
- Refractory ischemia
- Ischemia with hemodynamic or electrical instability
Use Clinical Decision Making rules such as HEART/GRACE score to further risk stratify them and most important - Document medical decision-making and Clinical Decision rules in the patient's record.
Read more on HEART SCORE on REBELEM.
- A good history helps in risk stratification. Don’t rule out ACS just based on the history alone. With the slightest of concern, get an ECG.
- It is okay to send troponins on your patients if you have some degree of concern but If there are no concerns eat all, then do not send troponins.
- Patients who present with chest pain with suspected cardiac ischaemia based on the history but normal ECG should still undergo further diagnostic testing.
- USA can have an ischemic or normal ECG but should always have negative troponins by definition.
- Low Risk - Do Serial ECGs, Shared Decision Making, Clinical Decision Making Rules to further risk stratify and DOCUMENT the decision making in the medical record.