Intended for healthcare professionals

Practice Easily Missed?

Recognising acute coronary syndrome

BMJ 2022; 377 doi: (Published 13 April 2022) Cite this as: BMJ 2022;377:e069591
  1. Ralf E Harskamp, general practitioner, assistant professor1,
  2. Alexander C Fanaroff, interventional cardiologist, assistant professor2,
  3. Sinead Wang Zhen, senior family physician, assistant professor3,
  4. Hendry R Sawe, emergency medicine specialist, senior lecturer4,
  5. Ellen J Weber, emergency physician, professor5
  1. 1Department of general practice, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
  2. 2Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, PA, USA
  3. 3Duke-NUS family medicine, SingHealth Polyclinics, Singapore, Singapore
  4. 4Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
  5. 5Department of Emergency Medicine, University of California, San Francisco, USA
  1. Correspondence to: R E Harskamp r.e.harskamp{at}, r.e.harskamp{at}

What you need to know

  • Consider the possibility of acute coronary syndrome in any patient with new onset or worsening chest discomfort (pain, pressure, tightness), dyspnoea, or localised symptoms outside the chest (such as arm, throat, or jaw), occurring while at rest and have a low threshold for emergency department referral of patients with ongoing symptoms

  • Delay in seeking medical attention is common, and more often reported in women, older adults, and those with high chronic disease burden

  • Administer aspirin (acetylsalicylic acid) in patients suspected of acute coronary syndrome and arrange immediate transfer by ambulance. Glyceryl trinitrate can be given for pain relief but should be used with caution if there is hypotension

  • A prehospital electrocardiogram should be used to identify ST segment elevation, which requires immediate coronary reperfusion in a cardiac catheterisation laboratory, whereas those without ST segment elevation should undergo rapid evaluation and risk stratification at the emergency department

A 72 year old woman with hypertension and diabetes was evaluated by her general practitioner for shortness of breath that developed over the course of several hours and increased on exertion. On presentation, she denied chest pain, but she did mention tiredness and shoulder pain that started in the preceding weeks. She had contacted the general practice the previous week, and, during the telephone consultation, her symptoms were interpreted as the aftereffects of covid-19, which kept her under the weather for the past three weeks. Her vitals at presentation were breathing rate of 22 breaths/min, SpO2 94%, blood pressure of 165/95 mm Hg, regular pulse of 130 bpm, blood glucose of 16 mmol/L, and temperature 36.7°C. She had basal crackles on pulmonary auscultation, normal heart sounds, and peripheral oedema. Her GP suspected acute heart failure and requested an ambulance transfer to a nearby hospital. Subsequent diagnostic work-up revealed that a blocked proximal left anterior descending coronary artery …

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