Red flags
- Refractory ischaemic chest pain
- Hypotension, HF, arrhythmia
- Dynamic ECG ST changes
- Troponin rising rapidly
First steps
- ECG + troponin at 0 and 1 h (ESC 0/1 h algorithm)
- Aspirin 300 mg + ticagrelor 180 mg
- Fondaparinux 2.5 mg SC OD (or enoxaparin 1 mg/kg BD)
- GTN if BP allows, morphine if refractory pain
Key investigations
- Serial ECG
- hs-troponin at 0/1 or 0/3 h
- Echo (regional wall motion, EF)
- GRACE score for risk
Differentials
- STEMI (activate PCI)
- PE
- Aortic dissection
- Myopericarditis
Initial management
- High risk (GRACE >140, dynamic ST, ongoing pain) → invasive <24 h
- Intermediate risk → invasive <72 h
- Low risk → non-invasive testing
- β-blocker, high-intensity statin, ACEi within 24 h
Referral
- Cardiology admit + PCI referral
- Cardiac rehab post-discharge
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