Remember: is it a haemolysed blood sample? (you can do an iSTAT)
Severity
Target:
Door to balloon 90min
Criteria Time:
Chest pain within 12hrs (or worsened within 12hrs)
ECG:
ST elevation MI (2 contiguous: 1mm Limb or 2mm Chest leads)
New LBBB.
(Posterior MI do posterior leads and discuss with LGI)
Actions:
Resuscitate as required
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Medication:
Prasagrel 60mg if – no previous CVA
Ticagrelor 180mg if previous CVA and Aspirin 300mg
Anti-coagulated Discuss with PPCI team
Aortic Dissection (AD), is uncommon (1:980 non-traumatic chest pain) but is…Rapidly FATAL! However, is testable for 80% if recognised early, unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%.
Read moreRecognising that someone may be approaching the end of their life can be difficult, particularly in the busy and sometimes unpredictable environment of the Emergency Department. We may meet people and families at a moment of profound distress, with little time to build a relationship or understand what matters most to them. It is understandable that these conversations feel daunting.
Yet recognising the possibility of dying creates an opportunity to offer the right care: to treat distress, consider reversible problems, explain uncertainty honestly and help patients and those close to them make informed choices. End of life care is not an alternative to good emergency medicine; it is part of it. Compassionate care remains active care.
Read more
It’s essential any Modifiable causes are treated, these include:
“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”
In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.
Arrhythmia clinic is for patients with newly diagnosed and symptomatic AF/SVT (if the patient is not symptomatic they should be followed up through their GP).
It should be remembered that patients will be seen after at least 6 weeks so anticoagulation decisions should not be delayed for clinic.
Based primarily on:
EMbeds clinical quick guide
Last evidence review: October 2026
Suggested next review: October 2026
This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.
First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.
Read more: Acute Coronary Syndrome (ACS) – 2025
Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),
Direct admissions to CCU
Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.
As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.
Patients where MI is excluded
If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:
Severity – Severe or Life threatening – think RESUSLink to ALL Trust protocols – HERE
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