ACS / STEMI

ACS /

STEMI

JRCALC Dec 2025 · NWAS Additional Guidance · v1.0

⚡ Take defibrillator to patient immediately. VF risk highest in first hours.

⚠️ A normal ECG does NOT exclude ACS. Many patients — especially women, older people and diabetics — do not present classically.

Symptom Assessment

Pain / Discomfort

Character

Central chest

Tight / constricting

Heavy / crushing

Burning

Sharp / stabbing

Epigastric

Radiation

Jaw / neck

Arm(s)

Between shoulders

Back

No radiation

Duration

Less than 20 min

More than 20 min ⚠️

Intermittent

Time since onset

Under 12 hours

12–48 hours (if ongoing/intermittent pain)

Over 48 hours

Associated Features

Nausea / Vomiting

Marked sweating

Breathlessness

Pallor

Clammy / cold skin

Feeling of impending doom

Syncope

Hypotension ⚠️

Pulmonary oedema ⚠️

Arrhythmia ⚠️

Risk Factors

Smoking

High cholesterol

Older age

Family history IHD

Known IHD / PVD

Diabetes

Chronic kidney disease

Hypertension

Equity Flags IMPORTANT

These groups have higher mortality, more atypical presentations, and are less likely to receive guideline care. Lower threshold for ECG and PPCI referral.

♀ Female

BAME background

Older patient

Diabetic

Cognitive impairment

♀ Women more likely to present with: pain between shoulders, nausea/vomiting, breathlessness. More likely to delay seeking help. Less likely to receive ECG or guideline care. Act quickly.

BAME patients tend to be younger at presentation, have higher rates of diabetes/hypertension/CKD, are less likely to use ambulance service, and had worse outcomes during COVID pandemic. Lower threshold for ECG and PPCI discussion.

⚠️ Pain onset over seconds/minutes = more likely ACS. Truly sudden onset = consider aortic dissection — refer to Think Aorta / Vascular Emergencies.

12-Lead ECG Assessment

🎯 ECG within 10 minutes of first patient contact — START ECG TIMER

PPCI Referral — ECG Criteria NWAS

Tap each lead group — mark STEMI, Normal, or Not done

V2–V3 ST Elevation

V2–V3

♀ Women: >1.5mm · ♂ Men: >2mm

⚡ STEMI

✓ Normal

N/D

Other Contiguous Leads

Any other 2 contiguous leads

ST elevation >1mm in any 2 contiguous leads

⚡ STEMI

✓ Normal

N/D

Posterior STEMI (V1–V3 Depression)

V1–V3 Depression + V7–V9

ST depression V1–V3 WITH ST elevation >0.5mm in V7–V9

⚡ STEMI

✓ Normal

N/D

Bundle Branch Block

LBBB

New LBBB + clear clinical features of AMI (cardiac chest pain, looks unwell)

⚡ PPCI

✓ No LBBB

N/D

RBBB

RBBB + ST elevation = discuss with PPCI centre · RBBB without ST elevation = unlikely AMI

RBBB + STE

RBBB no STE

No RBBB

Widespread ST Changes (Not Meeting Above)

Widespread ST Depression / Changes

Unwell patient + widespread ST depression not fitting above = discuss with PPCI centre

PRESENT

Absent

N/D

Normal / Non-Diagnostic ECG

Normal ECG does NOT exclude ACS — treat clinically

Repeat 12-lead ECG at least every 10 minutes if initial not diagnostic

Be prepared to change destination if STEMI develops en-route

Transmit ECG for expert review if uncertainty — use local pathway

Automated interpretation is a support tool — not definitive

Transient ST elevation — take seriously. Seek senior clinical advice.

STEMI Management

🚨 TIME-CRITICAL — Minimise on-scene time. Get moving to PPCI centre. All interventions en-route where possible.

🟣 NWAS: Follow NWAS STEMI Criteria for PPCI per local network pathways

Immediate Actions

Defibrillator with patient — continuous cardiac monitoring until hospital handover

Limit patient movement and walking — reduce myocardial stress

Direct admission to PPCI centre ('Heart Attack Centre') per local network pathway

ATMIST pre-alert to PPCI centre as early as possible

IV access — LEFT arm (right radial artery used for PPCI access)

Oxygen ONLY if SpO₂ <94% — do not give routinely (hyperoxia may cause coronary vasoconstriction)

⚠️ Post-ROSC with ST elevation — take to PPCI-capable hospital regardless of conscious level

⚠️ Pregnant STEMI — transfer to nearest PPCI centre, ideally co-located with obstetric services

Drugs

Record time given for each drug below

Aspirin as soon as possible

300mg oral — chewed or dispersible

P2Y12 Inhibitor per local policy

Ticagrelor / Prasugrel — follow local protocol

Opiate Analgesia first line for STEMI

Morphine IV/IO — titrate to pain. IV paracetamol or Entonox if morphine contraindicated.

Anti-emetic when giving opiate

Ondansetron or Metoclopramide — refer to drug guideline

GTN CAUTION

NOT routinely recommended in STEMI. Use cautiously for symptom relief of chest pain OR to reduce preload in pulmonary oedema / hypertension ONLY.

⚠️ GTN contraindicated if: hypotension, suspected right ventricular infarction, recent sildenafil/tadalafil use

Ongoing En-Route

Continuous cardiac monitoring throughout

Repeat 12-lead ECG every 10 minutes or if condition changes

Vital signs monitored — HR, BP, SpO₂, RR

Blood glucose — record en-route (do not delay departure for BM)

Pain scores recorded at regular intervals

Be prepared to change destination if rhythm or ECG changes

ACS / Non-STEMI Management

High risk — treat as medical emergency. Normal ECG does NOT exclude ACS.

Time-Critical Features — If Any Present

Major CABCDE problems

STEMI or BBB with clinical ACS features on ECG

Suspected ACS with haemodynamic instability

ATMIST Pre-Alert

Complete this and call PPCI centre / receiving hospital as early as possible. Pre-alerting speeds appropriate treatment.

A

Age / Sex

T

Time of onset / Call

M

Mechanism / Presenting complaint

I

Injuries / Findings

S

Signs / Observations

T

Treatment / ETA

ACS

Summary

JRCALC Dec 2025 · Aide-memoire only — complete full PCR separately

⚠️ Aide-memoire only. Complete full PCR separately.

Pain / Discomfort

Associated Features

Risk Factors

Equity Flags IMPORTANT

PPCI Referral — ECG Criteria NWAS

Normal / Non-Diagnostic ECG

Immediate Actions

Drugs

Ongoing En-Route

Time-Critical Features — If Any Present

Management

PRE-ALERT SUMMARY