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Chest Pain Hub

Chest pain is one of the most common and potentially life-threatening presentations in cardiology. This module covers the full ACS spectrum (STEMI, NSTEMI, Unstable Angina), advanced ECG interpretation, high-sensitivity troponin protocols, HEART score risk stratification, dangerous mimics, and bilingual nurse communication.

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💢Chest Pain & ACS

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Pre-Test — Chest Pain

~2 min

Answer a few quick questions before starting to measure your learning gain.

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Overview

Learning Objectives

1.Distinguish STEMI, NSTEMI, and Unstable Angina by ECG and troponin findings
2.Recognize high-risk ECG patterns: Wellens, de Winter T-waves, posterior MI, new LBBB
3.Apply high-sensitivity troponin rise/fall protocols and interpret delta troponin
4.Apply the HEART score for risk stratification and know the routing for each tier
5.Distinguish Type 1 from Type 2 MI and name causes of troponin elevation beyond ACS
6.Identify dangerous chest pain mimics: aortic dissection, PE, pericarditis, myocarditis
7.Execute the immediate nurse assessment protocol for chest pain, including time-sensitive targets
8.Communicate effectively with Spanish-speaking patients about chest pain using bilingual phrases
9.Recognize atypical ACS presentations in women, older adults, and diabetic patients

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APP Lesson: Chest Pain Evaluation

Audience: New cardiology APPs, PA/NP students, and clinicians new to cardiology.

Why Chest Pain Demands Attention

›Chest pain accounts for over 8 million emergency department visits annually in the United States. While the majority do not have ACS, the consequences of missing a STEMI, NSTEMI, aortic dissection, or pulmonary embolism are severe enough that every chest pain presentation must be approached with a systematic, evidence-based evaluation.
›As an APP in cardiology, you will encounter chest pain in many settings — ED referrals, urgent calls from clinic patients, triage assessments, and inpatient consultations. Your goal is to rapidly distinguish the life-threatening from the benign while communicating clearly with your team and your patient.
›A critical principle: a normal initial ECG does not rule out ACS. Up to 5% of acute MI patients have a normal ECG on presentation. Serial ECGs, serial troponins, and clinical gestalt must be used together.

The ACS Spectrum: STEMI, NSTEMI, and Unstable Angina

›All three ACS subtypes share a common pathophysiology: atherosclerotic plaque rupture or erosion with overlying thrombus formation. The clinical difference lies in the degree of coronary artery occlusion and resultant myocardial injury.
›STEMI (ST-Elevation Myocardial Infarction): Complete or near-complete occlusion of a coronary artery. Defined by ST elevation ≥1 mm in ≥2 contiguous limb leads, ≥2 mm in ≥2 contiguous precordial leads, or new left bundle branch block (LBBB). Requires emergent reperfusion — primary PCI within 90 minutes of first medical contact (door-to-balloon time). Every minute of delay = additional myocardial cell death.
›NSTEMI (Non-ST-Elevation Myocardial Infarction): Partial occlusion or transient complete occlusion with spontaneous reperfusion. Troponin is elevated (myocardial necrosis has occurred) without ST elevation on ECG. ST depression, T-wave inversions, or a normal ECG may be present. Managed with risk-stratified approach — high-risk NSTEMI may require early invasive strategy within 24 hours.
›Unstable Angina (UA): Ischemic symptoms at rest or with minimal exertion without troponin elevation. Plaque rupture with thrombus but no myocyte necrosis. Increasingly rare as a distinct diagnosis with high-sensitivity troponins, which detect injury at much lower thresholds than previous-generation assays. Still a clinically meaningful entity when troponin is negative.
›Key clinical implication: you cannot distinguish STEMI from NSTEMI from UA on history alone. The ECG and troponin results are required.

Characterizing the Chest Pain History

›OPQRST remains the backbone of chest pain characterization: Onset, Provocation/Palliation, Quality, Radiation, Severity, and Timing. Each element narrows the differential.
›Classic ischemic chest pain: pressure, squeezing, or heaviness in the substernal area, often radiating to the left arm, jaw, or back. Associated diaphoresis, nausea, or dyspnea markedly increases concern for ACS.
›Onset: Sudden maximal onset suggests aortic dissection or PE. Gradual worsening over hours to days can suggest ACS or pericarditis. Brief, fleeting pain lasting seconds is rarely ischemic.
›Provocation: Pain that consistently worsens with exertion and improves with rest is highly suggestive of angina. Pain reproduced by palpation suggests musculoskeletal etiology. Pain worse with inspiration points toward pleuritis, PE, or pericarditis.
›Atypical presentations: Women, older adults, and patients with diabetes frequently present with atypical symptoms — fatigue, nausea, jaw pain, arm discomfort without chest pain, unexplained dyspnea, or unusual fatigue. These must not be dismissed. ACS in these populations is consistently underrecognized and undertreated. When in doubt, get the ECG.

ECG Interpretation for Chest Pain

›Obtain ECG within 10 minutes of presentation — it is the single highest-yield test. Compare to any prior ECG whenever possible; dynamic changes are as important as the absolute findings.
›ST Elevation: The "tombstone" or convex upward pattern is the classic STEMI morphology. Territory matters: II, III, aVF = inferior (RCA or LCx); V1–V4 = anterior (LAD); I, aVL, V5–V6 = lateral (LCx or diagonal); V1–V2 with right-sided leads = right ventricular MI (inferior STEMI + right heart involvement).
›ST Depression: Represents subendocardial ischemia. In V1–V3, ST depression with upright T-waves may represent a posterior MI — obtain posterior leads V7–V9 to look for posterior ST elevation.
›Wellens Pattern (HIGH YIELD): Biphasic or deep symmetric T-wave inversions in V2–V3 (sometimes extending to V4) in a patient who has had chest pain that is now resolving. Represents critical proximal LAD stenosis with spontaneous reperfusion. Do NOT stress test these patients — they are at extreme risk of massive anterior MI. Requires urgent cardiology evaluation.
›de Winter T-waves: Upsloping ST depression in V1–V6 with prominent, peaked (hyperacute) T-waves. This is an LAD occlusion equivalent — treat as STEMI. Often missed because the pattern does not look like classic ST elevation.
›LBBB: New or presumably new LBBB in the setting of chest pain is a STEMI equivalent and should trigger cath lab activation. Sgarbossa criteria help identify underlying STEMI in the presence of LBBB: concordant ST elevation ≥1 mm (score 5), concordant ST depression ≥1 mm in V1–V3 (score 3), discordant ST elevation ≥5 mm (score 2). Score ≥3 is highly specific for AMI.
›Right-sided leads: In inferior STEMI, always obtain right-sided leads (V3R, V4R) to evaluate for right ventricular MI. RV MI is treated differently — avoid nitrates and preload-reducing agents, which can cause severe hypotension.
›Pericarditis pattern: Diffuse ST elevation in multiple non-contiguous leads with PR depression. Saddle-shaped morphology. Does not follow coronary territory. Reciprocal changes absent.

High-Sensitivity Troponin Protocols

›High-sensitivity troponin (hs-cTn) has transformed chest pain evaluation. It detects myocardial injury at very low concentrations and enables accelerated rule-in/rule-out protocols. Most institutions use 0h/1h, 0h/2h, or 0h/3h protocols — know your institution's assay and thresholds.
›Rise and fall pattern: Acute myocardial injury causes a rising and falling troponin pattern. A single elevated troponin is not diagnostic alone — chronic elevations from renal failure, heart failure, or myocarditis can cause persistent, stable elevations. The delta troponin (absolute change from baseline to repeat draw) is what identifies acute injury.
›Delta troponin significance: Each assay has specific delta thresholds. In general, a significant absolute rise (e.g., >5–6 ng/L for some hs-cTnT assays at 1 hour) in the appropriate clinical context is consistent with AMI. Falling levels suggest the injury has peaked.
›Type 1 MI vs Type 2 MI: Type 1 MI = acute plaque rupture/erosion with thrombosis (classic ACS). Type 2 MI = myocardial oxygen demand-supply mismatch without acute coronary plaque event — caused by tachyarrhythmia, severe hypertension, hypotension, sepsis, or severe anemia. Type 2 MI is common in hospitalized patients. Treatment targets the underlying cause, not necessarily PCI.
›Other causes of troponin elevation: Myocarditis, pulmonary embolism, sepsis/critical illness, acute heart failure, renal failure (impaired clearance), cardioversion, cardiac ablation, blunt chest trauma, subarachnoid hemorrhage, Takotsubo cardiomyopathy. Always interpret troponin in clinical context.
›For STEMI: Do NOT wait for troponin. ST elevation on ECG with symptoms is a clinical diagnosis requiring immediate cath lab activation — troponin results should not delay reperfusion.

HEART Score in Practice

›The HEART score is a validated clinical decision tool for risk stratification of chest pain. Use it for patients where ACS is on the differential but STEMI has been excluded. Use the interactive HEART Score Calculator in Clinical Tools.Open HEART Score Calculator
›H — History: 2 = highly suspicious (classic anginal pressure, radiation, diaphoresis, onset at rest); 1 = moderately suspicious (some typical features); 0 = slightly suspicious or clearly non-ischemic character.
›E — ECG: 2 = significant ST depression, dynamic changes, or new LBBB; 1 = non-specific repolarization disturbance, T-wave changes, old LBBB; 0 = normal ECG.
›A — Age: 2 = ≥65 years; 1 = 45–64 years; 0 = <45 years.
›R — Risk Factors: 2 = known atherosclerotic disease (prior MI, PCI, CABG, stroke, peripheral artery disease); 1 = ≥3 cardiac risk factors (HTN, DM, HLD, obesity, smoking, family Hx); 0 = no known risk factors.
›T — Troponin: 2 = >3× normal upper limit of normal; 1 = 1–3× ULN; 0 = ≤ normal limit.
›Score 0–3: Low risk — approximately 1–2% MACE risk at 30 days. Early discharge with outpatient follow-up may be appropriate per institutional protocol.
›Score 4–6: Intermediate risk — approximately 12–17% MACE risk. Further observation, serial troponins, and additional workup warranted. Cardiology input recommended.
›Score 7–10: High risk — approximately 50–65% MACE risk. Presumed ACS; cardiology input and likely early invasive strategy required.

Dangerous Chest Pain Mimics — Clinical Pearls

›Aortic Dissection: Sudden onset, tearing or ripping pain — often maximal at onset. Radiates to the back (thoracic) or abdomen (abdominal). BP differential >20 mmHg between arms, pulse deficits, new aortic regurgitation murmur. Widened mediastinum on CXR. Confirm with CT angiography of chest/abdomen. CRITICAL: Do NOT give thrombolytics or aggressive anticoagulation without ruling out dissection — it can be fatal.
›Pulmonary Embolism: Pleuritic chest pain (sharp, worsens with breathing), dyspnea, tachycardia, hypoxia. Assess Wells PE score. D-dimer for low-to-intermediate pretest probability. CT pulmonary angiography is the diagnostic study of choice. Massive PE with hemodynamic instability may require systemic thrombolysis.
›GERD / Esophageal: Burning, substernal, radiates to throat. Associated with meals, lying flat, or acidic foods. May respond to antacids (GI cocktail). NOTE: Esophageal spasm can respond to nitrates — symptomatic response to nitroglycerin does NOT confirm cardiac etiology.
›Musculoskeletal / Costochondritis: Pain reproducible with direct palpation at costochondral junctions or chest wall. Positional. History of prior trauma, strain, or vigorous coughing. However, chest wall tenderness does not completely exclude ACS — studies show ~6% of patients with reproducible tenderness had ACS.
›Anxiety / Panic Disorder: Chest tightness, palpitations, dyspnea, perioral tingling, situational trigger, hyperventilation. Young patient with no risk factors. ALWAYS a diagnosis of exclusion — rule out cardiac and pulmonary causes first.
›Pericarditis: Sharp, pleuritic pain — worse lying flat, better leaning forward. Pericardial friction rub on exam (scratchy, three-component sound, best heard leaning forward). ECG shows diffuse ST elevation with PR depression, saddle-shaped morphology. History of viral illness in days prior. Treat with NSAIDs + colchicine. Avoid strenuous activity during acute phase.
›Myocarditis: Young patient (often 20s–40s), viral prodrome (fever, myalgias, upper respiratory symptoms) in prior 1–2 weeks. Troponin elevation with ECG changes (diffuse ST changes, LBBB). Echo may show wall motion abnormalities or reduced EF. CMR is diagnostic. Treatment is supportive; restrict activity.
›Pneumothorax: Sudden unilateral pleuritic pain with dyspnea. Decreased or absent breath sounds on affected side. CXR confirms. Tension pneumothorax causes hemodynamic instability — tracheal deviation, absent breath sounds, hypotension = immediate needle decompression.

Nurse Escalation Framework

›Immediate 12-lead ECG for ANY chest pain complaint — do not wait for provider order, do not wait for triage completion, do not wait for registration. ECG first.
›Oxygen: Apply only if SpO2 <90%. Routine high-flow oxygen in normoxic ACS patients does not improve outcomes and may increase infarct size.
›IV access and continuous cardiac monitoring for all chest pain patients until etiology is established.
›STEMI recognition criteria on ECG → activate cath lab protocol immediately per institutional STEMI alert protocol. Do not wait to call the attending first — follow the protocol, then notify.
›Hemodynamic instability (systolic BP <90 mmHg, heart rate >120 bpm with diaphoresis, altered mental status) → immediate provider notification and preparation for resuscitation.
›Time-sensitive documentation: Record time of symptom onset, time of first ECG, time provider notified. Door-to-ECG target: <10 minutes. Door-to-balloon target: <90 minutes. These metrics directly correlate with outcomes.
›Document the symptom onset time as reported by the patient — this is the start of the clock for door-to-balloon time calculation.

Initial Workup for Chest Pain

›ECG — obtain within 10 minutes of presentation. Look for STEMI, new LBBB, ST depression, T-wave inversions, Wellens pattern, de Winter T-waves, posterior changes. Compare to prior ECG whenever possible.
›Serial troponins — baseline and at 1–3 hours depending on protocol and assay used. Document exact draw times.
›Chest X-ray — evaluate for widened mediastinum (dissection), pneumothorax, pulmonary congestion, cardiomegaly, effusion.
›BMP — renal function, electrolytes; important before contrast administration or anticoagulation.
›CBC — anemia as precipitant (demand ischemia / Type 2 MI); leukocytosis if infection suspected.
›Lipid panel if not recent — add to chart for risk assessment and longitudinal care.
›D-dimer — if PE is on the differential and pretest probability is low to intermediate (Wells PE score).
›CT angiography of chest — for aortic dissection or PE when clinically suspected and hemodynamically stable.
›Right-sided ECG leads (V3R, V4R) — obtain in ALL inferior STEMIs to evaluate for RV involvement.
›Posterior leads (V7–V9) — obtain when posterior MI is suspected (ST depression V1–V3 with upright T-waves).

Red Flags Requiring Immediate Escalation

›ST elevation or new LBBB on ECG — activate cath lab immediately
›de Winter T-waves or Wellens pattern — urgent cardiology notification
›Hemodynamic instability: hypotension, shock, altered mental status
›Severe diaphoresis with chest pain
›Syncope or near-syncope with chest pain
›Rapidly rising troponin (delta positive)
›Oxygen desaturation below 90%
›Ventricular tachycardia or ventricular fibrillation
›Signs of acute heart failure in the setting of chest pain
›BP differential >20 mmHg between arms (dissection concern)
›New pulse deficit or asymmetric pulses

Risk Stratification Tools

›HEART Score — the primary risk stratification tool for undifferentiated chest pain. Available in the Clinical Tools section. Guides disposition: low (0–3), intermediate (4–6), high (7–10).HEART Score Calculator
›TIMI NSTEMI Score — alternative risk tool using 7 variables: age ≥65, ≥3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation on ECG, ≥2 anginal events in 24h, aspirin use in prior 7 days, elevated serum cardiac markers. Score 0–7, higher = more events.
›GRACE Score — Global Registry of Acute Coronary Events score. Uses Killip class, BP, HR, age, creatinine, cardiac arrest at presentation, ST deviation, and troponin. More complex but validated for in-hospital and 6-month mortality.
›These tools are additive to clinical judgment — not replacements. A low HEART score in a patient with a convincing story and new ECG changes warrants continued concern despite the number.

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Clinical Cheat Sheet

Time-Sensitive Targets

•Door-to-ECG: < 10 minutes
•Door-to-Balloon (STEMI PCI): < 90 minutes
•Door-to-Needle (thrombolytics if PCI unavailable): < 30 minutes
•First troponin draw: at presentation (time 0)
•Second troponin draw: per protocol (0/1h, 0/2h, or 0/3h)
•Document exact time of symptom onset from patient report

ACS Subtype Comparison

•STEMI: ST elevation ≥1mm (limb) / ≥2mm (precordial) in ≥2 contiguous leads; or new LBBB | Troponin: elevated | Action: emergent PCI
•NSTEMI: No ST elevation | Troponin: ELEVATED | Action: risk-stratified, early invasive if high risk
•Unstable Angina: No ST elevation | Troponin: NEGATIVE | Action: observation, risk stratification, stress testing
•All three share pathophysiology: plaque rupture + thrombus; differ in degree of occlusion
•A normal ECG does NOT rule out ACS — up to 5% of AMI have normal initial ECG

ECG Quick Reference by Pattern

•ST elevation II, III, aVF → Inferior STEMI (RCA or LCx) — get right-sided leads!
•ST elevation V1–V4 → Anterior STEMI (LAD territory)
•ST elevation I, aVL, V5–V6 → Lateral STEMI (LCx or diagonal)
•ST depression V1–V3 + upright T → Posterior MI — get V7–V9
•Wellens pattern (biphasic/deep T inv V2–V3) → Proximal LAD stenosis — DO NOT stress test
•de Winter T-waves (upsloping ST depression + peaked T) → LAD occlusion equivalent — treat as STEMI
•New LBBB + symptoms → STEMI equivalent — activate cath lab; apply Sgarbossa criteria
•Diffuse ST elevation + PR depression (saddle shape) → Pericarditis
•RV MI clue: Inferior STEMI + hypotension + clear lungs — check V4R

HEART Score (0–10)

•H — History: 0 (low suspicion) | 1 (moderate) | 2 (highly suspicious/classic anginal)
•E — ECG: 0 (normal) | 1 (non-specific/old LBBB) | 2 (significant ST changes/dynamic)
•A — Age: 0 (<45) | 1 (45–64) | 2 (≥65)
•R — Risk: 0 (none) | 1 (≥3 risk factors) | 2 (known atherosclerotic disease)
•T — Troponin: 0 (≤ULN) | 1 (1–3×ULN) | 2 (>3×ULN)
•0–3 = Low (~2% MACE) → possible early discharge + outpatient f/u
•4–6 = Intermediate (~15% MACE) → observe, serial troponins, further eval
•7–10 = High (~50–65% MACE) → early invasive strategy
•Use HEART Score Calculator at /tools/acs/heart

Troponin Rise/Fall Guide

•Single troponin is NOT sufficient — serial draws with delta are required
•Delta (change) = what identifies ACUTE injury vs chronic elevation
•Rising + falling pattern → acute MI (confirms AMI with clinical context)
•Stable, mildly elevated → chronic elevation (HF, CKD, myocarditis baseline)
•Type 1 MI: plaque rupture/thrombosis → treat with ACS protocol
•Type 2 MI: demand ischemia (tachyarrhythmia, sepsis, anemia) → treat underlying cause
•Other causes of elevated troponin: PE, myocarditis, sepsis, CKD, HF, cardioversion, ablation, Takotsubo

Chest Pain Differential — 10 Key Diagnoses

•STEMI/NSTEMI/UA: Pressure, radiation, diaphoresis, nausea | ECG changes, troponin | Cath lab / ACS protocol
•Aortic Dissection: Tearing/ripping, max at onset, radiates to back | BP differential >20mmHg, wide mediastinum | CT angio — NO thrombolytics
•Pulmonary Embolism: Pleuritic, dyspnea, tachycardia, hypoxia | Wells score, D-dimer, CTPA | Anticoagulation / thrombolytics if massive
•Pericarditis: Sharp, pleuritic, better leaning forward | Diffuse ST elev + PR depression, friction rub | NSAIDs + colchicine
•Myocarditis: Young patient, viral prodrome, troponin elevation | Diffuse ECG changes, echo WMA | Supportive, activity restriction
•GERD/Esophageal: Burning, post-meal, lying flat, throat | Responds to antacids | PPI, GI referral (note: nitrate response ≠ cardiac)
•Musculoskeletal: Reproducible on palpation, positional, pleuritic | Tenderness at costochondral junction | NSAIDs, reassurance
•Anxiety/Panic: Situational, tachycardia, tingling, hyperventilation | Normal ECG and troponin | Diagnosis of exclusion
•Pneumothorax: Sudden unilateral, decreased breath sounds | CXR confirms | Needle decompression if tension
•Myocardial Demand Ischemia (Type 2 MI): Troponin elevated, known trigger (tachyarrhythmia, sepsis, severe anemia) | No culprit plaque | Treat underlying cause

Immediate Nurse Actions Checklist

•1. 12-lead ECG IMMEDIATELY — before anything else
•2. Place on continuous cardiac monitor
•3. Establish IV access
•4. Vital signs including SpO2 (and bilateral BP if dissection concern)
•5. Notify provider with ECG findings
•6. Apply O2 ONLY if SpO2 <90%
•7. Document time of symptom onset (patient report) and time of first ECG
•8. STEMI on ECG → activate STEMI protocol per institution
•9. Prepare for potential emergent transport to cath lab

Escalate Immediately If

•ST elevation or new LBBB on ECG
•de Winter T-waves or Wellens pattern
•Hemodynamic instability (low BP, shock, altered MS)
•Severe diaphoresis + chest pain
•Syncope or near-syncope
•Rapidly rising troponin (positive delta)
•SpO2 <90%
•BP differential >20 mmHg between arms
•Ventricular arrhythmia on monitor
•Signs of cardiogenic shock or acute HF

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Nurse Assessment Checklist

Rapid, systematic chest pain assessment to gather critical information before provider evaluation and support time-sensitive ACS protocols.

Immediate Actions — First 5 Minutes (In Order)

STEP 1: Obtain 12-lead ECG IMMEDIATELY — before history, before vitals, before anything else
STEP 2: Place patient on continuous cardiac monitor
STEP 3: Establish IV access (at least one large-bore peripheral IV)
STEP 4: Obtain vital signs: HR, BP (BOTH arms if dissection concern), RR, SpO2, temperature
STEP 5: Apply supplemental oxygen ONLY if SpO2 <90% (avoid routine O2 in normoxic patients)
STEP 6: Notify provider immediately with ECG findings and vitals — do not wait
STEP 7: Draw troponin stat — document exact draw time
STEP 8: Document time of symptom onset (ask patient/family: "When exactly did this start?")
STEP 9: If STEMI criteria on ECG → activate STEMI/cath lab protocol per institution protocol — do not delay

OPQRST Pain Assessment

O — Onset: When did it start? Did it come on suddenly or gradually?
P — Provocation/Palliation: What makes it better? What makes it worse? Does it hurt with breathing? Does it change with position?
Q — Quality: How would you describe it? Pressure? Squeezing? Sharp? Burning? Tearing? Heavy?
R — Radiation: Does it go anywhere? Arm? Jaw? Neck? Back? Shoulder?
S — Severity: On a scale of 0–10, how bad is the pain right now?
T — Timing: Is it constant or does it come and go? How long has it lasted?
Associated symptoms: Diaphoresis (sweating)? Nausea or vomiting? Shortness of breath? Dizziness or palpitations? Syncope?
Prior episodes: Has this happened before? Was it the same or different?

HEART Score Data Collection

H — History quality: Note if pain is classic anginal (pressure, radiation, diaphoresis, rest/exertion) vs atypical vs clearly non-cardiac
E — ECG: Note findings on 12-lead — normal, non-specific changes, ST elevation/depression, T-wave inversions
A — Age: Document patient age for scoring
R — Risk Factors: Ask about HTN, DM, hyperlipidemia, smoking, obesity, family Hx of early CAD
R — Known atherosclerotic disease: Prior MI, PCI, CABG, stroke, peripheral artery disease?
T — Troponin: Document result and exact draw time once resulted
Communicate HEART data points to provider in SBAR report

Troponin Timing Documentation

Time 0 troponin: draw at presentation — record exact time of draw
Repeat troponin: per institutional protocol (1h, 2h, or 3h) — record exact time of EACH draw
Delta calculation is performed by provider or lab — ensure draws are timed correctly
If patient has new symptoms during observation, notify provider and consider repeat ECG
Label all specimens clearly with draw time

Medical History to Gather

Prior cardiac history: CAD, prior MI, prior PCI or stents, CABG
History of hypertension, diabetes, hyperlipidemia
Smoking history (current, former, pack-years)
Family history of heart disease or early MI (<55 in men, <65 in women)
Recent surgeries, prolonged immobility, travel, DVT/PE history (PE risk)
Current medications including antiplatelets and anticoagulants
Allergies (especially aspirin, contrast, heparin)
Last meal — important if emergent procedure anticipated
For women: ask about unusual fatigue, jaw pain, nausea, arm discomfort without chest pain

Red Flags — Escalate Immediately

ST elevation or new LBBB on 12-lead ECG → STEMI protocol NOW
de Winter T-wave pattern or Wellens pattern → urgent provider notification
Patient appears diaphoretic, pale, or in significant distress
Systolic BP <90 mmHg or BP differential >20 mmHg between arms
Heart rate >120 bpm with symptoms
SpO2 <90% on room air
Syncope or presyncope
Pain described as sudden, tearing, radiating to back (dissection concern)
Ventricular tachycardia or fibrillation on monitor
Any clinical concern that the patient is unstable — trust your instincts

Patient Positioning and Comfort

Semi-recumbent or position of comfort unless hemodynamically unstable
Do NOT leave the patient alone if high-risk features are present
Reassure the patient calmly — "We are doing everything we can to take care of you right now"
Limit unnecessary stimulation if arrhythmia concern
Family presence per patient preference — family can provide important history
Ensure IV site is patent and secure — you may need it quickly

Documentation Requirements

Time patient arrived / time of first contact
Time of first 12-lead ECG
ECG findings (or note "sent to provider for interpretation")
Time provider notified and name of provider
Vital signs with time obtained
Time of troponin draw(s)
Symptom onset time as reported by patient
Patient's pain score (0–10) and description of symptoms
IV access: site, gauge, time placed
Any medications administered and time given
STEMI alert time if activated

SBAR Report to Provider

S — Situation: "I have a patient with chest pain who needs immediate evaluation."
B — Background: Age, sex, relevant cardiac history, current meds
A — Assessment: Vital signs, ECG findings, pain description, associated symptoms
R — Recommendation: "I need you at bedside now" OR "ECG shows ST elevation — initiating STEMI protocol"

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Patient Education Handout

Warning Signs of a Heart Attack

A heart attack does not always feel like you expect. Know ALL the warning signs:
•Chest pain, pressure, tightness, squeezing, or heaviness
•Pain or discomfort spreading to your left arm, right arm, jaw, neck, or back
•Shortness of breath — even without chest pain
•Sweating suddenly (cold sweat)
•Nausea or vomiting
•Unusual fatigue — feeling extremely tired without a clear reason
•Dizziness or lightheadedness
•Feeling like something is very wrong
IMPORTANT: Women, older adults, and people with diabetes may not have classic chest pain. They may have only unusual fatigue, nausea, jaw pain, or arm discomfort. These are still warning signs.

When to Call 911 Immediately

Call 911 right away — do NOT drive yourself — if you have:
•Any chest pain, pressure, or tightness that lasts more than a few minutes
•Chest discomfort along with sweating, nausea, or shortness of breath
•Pain spreading to your arm, jaw, back, or neck
•Sudden severe shortness of breath
•Feeling faint or losing consciousness
•A strong feeling that something is seriously wrong
Do NOT wait to see if it goes away. Do NOT drive yourself. Paramedics can start evaluation and treatment on the way to the hospital — this saves time and saves lives.
If you have been prescribed nitroglycerin, use it as instructed and still call 911.

When to Call the Clinic (Not 911)

Call your cardiology clinic (not 911) if you have:
•Chest pain that has FULLY resolved and you feel back to normal
•Mild, brief chest discomfort that you have had before and was evaluated as non-cardiac
•Questions about your medications or follow-up after a recent visit
If you are unsure — call 911. It is always better to be evaluated and told everything is fine than to wait when it is serious.

What Happens During a Cardiac Workup

When you come in with chest pain, your care team will work quickly:
•A heart tracing test (EKG or ECG) will be done within the first 10 minutes. It records your heart's electrical activity and helps identify a heart attack.
•Blood tests (troponin) check for proteins released when heart muscle is injured. These are often drawn twice — at the start and 1–3 hours later.
•A chest X-ray checks your lungs and heart.
•You will be placed on a heart monitor and may have an IV placed.
•Based on results, you may go home the same day, be observed for several hours, or need further testing or a procedure.
•If a heart attack is confirmed, you may need a cardiac catheterization — a procedure where a thin tube is used to look at and treat blocked arteries in your heart.

Know Your Risk Factors

Some things increase your risk of heart disease. Many can be managed:
•High blood pressure (hypertension)
•High cholesterol (hyperlipidemia)
•Diabetes
•Smoking or tobacco use
•Family history of heart attacks, especially in younger relatives
•Being overweight or physically inactive
•Chronic stress
Talk to your doctor about how to lower your risk through lifestyle changes and medications.

After Discharge: What To Do

Follow all instructions your care team gives you before you leave.
Take any new medications exactly as prescribed. Do not stop any heart medication without talking to your doctor first.
Keep all follow-up appointments — your care team needs to check on your recovery.
Activity: You may be told to avoid heavy lifting or strenuous exercise for a period of time. Follow these restrictions.
Diet: Follow any dietary instructions given, especially about sodium and heart-healthy eating.
Return to the emergency room or call 911 if any of these return: chest pain, shortness of breath, sweating with chest discomfort, arm or jaw pain, feeling faint.
Do not wait to see if symptoms go away again. Call 911.

This handout is for education only and does not replace medical advice from your healthcare team. Always follow the specific instructions given to you by your provider.

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Spanish / Communication Phrases

Interpreter Notice: These phrases are for basic communication and rapport only. Use a certified medical interpreter for diagnosis, treatment decisions, medication changes, consent, discharge instructions, and all complex clinical conversations.

Do you have chest pain?

¿Tiene dolor en el pecho?

When did the pain start?

¿Cuándo empezó el dolor?

Does the pain go to your arm or jaw?

¿Le va el dolor al brazo o a la mandíbula?

Are you sweating?

¿Está sudando?

Are you short of breath?

¿Le falta el aire?

Is the pain sharp or pressure?

¿El dolor es agudo o como presión?

We need to do a heart tracing test right now.

Necesitamos hacerle un electrocardiograma ahora mismo.

On a scale of 0 to 10, how bad is the pain?

En una escala del cero al diez, ¿qué tan fuerte es el dolor?

Do you have a history of heart problems?

¿Tiene historia de problemas del corazón?

Are you taking any blood thinners?

¿Está tomando algún anticoagulante?

Do you feel nauseous?

¿Tiene náuseas?

I am going to place an IV line in your arm.

Le voy a poner una vía intravenosa en el brazo.

We need an interpreter to explain the results and plan.

Necesitamos un intérprete para explicar los resultados y el plan.

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Sim Patient Case

Emergency Department / Cardiology Urgent EvaluationInteractive

Patient

[EN] 61-year-old male with type 2 diabetes, hypertension, hyperlipidemia, and prior PCI to the LAD 3 years ago. His wife called 911 after he woke up from sleep with severe chest pressure. [ES] Hombre de 61 años con diabetes tipo 2, hipertensión, hiperlipidemia y antecedente de intervención coronaria percutánea (PCI) a la arteria descendente anterior (LAD) hace 3 años. Su esposa llamó al 911 después de que él se despertó del sueño con una fuerte presión en el pecho.

Chief Complaint

[EN] "The pressure in my chest woke me up from sleep. It feels like something is sitting on my chest and my left arm is numb." [ES] "La presión en el pecho me despertó del sueño. Siento como si algo estuviera sobre mi pecho y mi brazo izquierdo está entumecido."

Vitals

146/88 mmHg (right arm) / 144/86 mmHg (left arm)

96 bpm — sinus rhythm

22 breaths/min

SpO2

92% on room air

Temp

98.4°F

Pain

8/10 — substernal pressure, radiating to left arm

Glucose

218 mg/dL (known diabetic)

Goal

[EN] Rapidly assess the patient, recognize inferior STEMI on ECG, activate the cath lab, perform bilingual nurse communication, and prioritize time-sensitive interventions. [ES] Evalúe al paciente con rapidez, reconozca el STEMI inferior en el ECG, active el protocolo del laboratorio de cateterismo, realice comunicación de enfermería bilingüe y priorice las intervenciones sensibles al tiempo.

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Knowledge Check Quiz

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Disclaimer: This content is for educational purposes only. It is not medical advice, does not replace clinical judgment, and is not a substitute for institutional protocols or certified medical interpreters. No patient health information (PHI) should be entered into this application.