Typical exam stem
A 58-year-old man presents with 90 minutes of central crushing chest pain, sweating and nausea. How would you assess and manage him?
Active exam mode
Plan the case before reading, then mark sections, reveal pearls and self-rate the viva.
1. Sixty-second answer plan
1:00Before reading the notes, say or write your assessment, investigations and management structure.
2. Section checklist
Mark each section only after you can explain its main decision points without reading.
3. Exam-pearl flashcards
Try to predict the pearl before revealing it.
4. Viva drill
Answer aloud before rating yourself. Anything marked “review” stays visible in your progress.
What are the major life-threatening differentials for acute chest pain?
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Start with the diagnosis you cannot afford to miss
Acute coronary syndrome (ACS) includes ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina. In an examination, the strongest answer begins by recognising possible myocardial ischaemia while simultaneously considering other lethal causes of chest pain such as aortic dissection, pulmonary embolism, tension pneumothorax and oesophageal rupture.
Do not wait for biomarkers before acting on a convincing presentation. The history, haemodynamic state and 12-lead ECG determine the urgency of the next step.
- Typical features: central pressure or heaviness, radiation to arm or jaw, autonomic symptoms and exertional or persistent pain.
- High-risk features: ongoing pain, hypotension, pulmonary oedema, malignant arrhythmia, syncope or dynamic ECG changes.
- A normal first ECG does not exclude ACS; repeat ECGs when symptoms persist or change.
Core investigations
- 12-lead ECG as early as possible, interpreted for ST elevation, ST depression, T-wave inversion, new conduction disturbance and rhythm.
- High-sensitivity cardiac troponin using the local validated serial pathway.
- Full blood count, renal function, electrolytes, glucose and other tests guided by the differential diagnosis.
- Chest radiograph when another thoracic diagnosis or heart failure is suspected; do not delay reperfusion for routine imaging.
- Echocardiography when diagnosis, ventricular function or mechanical complications require clarification.
Management framework examiners expect
State that the patient requires monitored care, intravenous access, repeated observations and early cardiology involvement. Give antiplatelet and anticoagulant therapy according to the working ACS diagnosis, bleeding risk and planned reperfusion strategy. Oxygen is indicated for hypoxaemia rather than as a routine treatment in a normally saturated patient.
For STEMI, the central management issue is urgent reperfusion, preferably primary PCI when it can be delivered within an appropriate system delay. For NSTE-ACS, use clinical risk, ECG changes, troponin and haemodynamic stability to determine the urgency of invasive coronary assessment.
- Treat pain and ischaemia while avoiding hypotension.
- Identify cardiogenic shock, acute mitral regurgitation, ventricular septal rupture, free-wall rupture and serious arrhythmia.
- Before discharge, address secondary prevention: antithrombotic therapy, lipid lowering, smoking cessation, cardiac rehabilitation and control of cardiovascular risk factors.
Guideline source for further reading
This page is an original exam-revision summary. For clinical decisions, use current local protocols and the primary guidance below.