Red flags
- Crushing/retrosternal pain >20 min, diaphoresis, radiation to arm/jaw
- Tearing interscapular pain + BP differential >20 mmHg arms
- Pleuritic pain + hypoxia + unilateral leg swelling (PE)
- Hypotension, syncope, new murmur
First steps
- ABCDE, IV access, continuous monitoring
- 12-lead ECG within 10 minutes
- SpO₂, BP both arms, focused cardiopulmonary exam
Key investigations
- ECG (serial q15 min if suspicion high)
- High-sensitivity troponin at 0 and 1–3 h
- CXR; D-dimer if PE suspected (use Wells/PERC first)
- Bedside echo if dissection or tamponade considered
Differentials
- ACS (STEMI/NSTEMI/UA)
- Pulmonary embolism
- Aortic dissection
- Pericarditis / myocarditis
- Pneumothorax / pneumonia
- GERD, MSK chest wall, anxiety
Initial management
- Aspirin 300 mg chewable if ACS suspected and no contraindication
- Sublingual GTN 0.4 mg unless RV infarct/hypotension
- Oxygen only if SpO₂ <90%
- STEMI → activate cath lab; door-to-balloon <90 min
Referral
- Cardiology for ACS pathway
- CT-surgery for dissection
- ICU if unstable
Patient counseling
- Recognize warning signs
- Strict medication adherence
- Smoking cessation, BP/lipid control
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