Chest Pain in a Patient With a 'Normal' ECG
A 58-year-old man with type 2 diabetes and hypertension presents to the emergency department at 02:00 with central chest pressure that started 40 minutes ago while he was resting. He describes it as 'heavy, like a band', radiating to the left arm, with sweating and nausea. He took two sublingual GTN tablets with no relief. Observations: HR 92, BP 148/88, RR 22, SpO2 95% on air, temperature 36.8 C. The triage nurse's 12-lead ECG shows no ST elevation and is reported as 'normal'. The department is full and there is a 3-hour wait to be seen. The nurse has a troponin result pending.
1. Does the 'normal' ECG exclude an acute coronary syndrome? What is the nurse's priority?
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No - a normal ECG does not exclude ACS. Up to half of patients with non-ST-elevation MI have a normal or non-diagnostic ECG on first presentation. This man has multiple high-risk features:
- Typical ischaemic symptoms: central pressure, radiation to the left arm, sweating, nausea.
- Cardiac risk factors: diabetes and hypertension. Diabetes can mask or alter symptoms and is a major risk factor.
- Pain at rest, lasting more than 20 minutes, not relieved by GTN.
- He is 58 and male.
Priority: treat as a possible ACS until proven otherwise. He must not wait 3 hours in a queue.
Actions:
- Move him to a monitored area and attach continuous cardiac monitoring, with defibrillator and airway equipment available.
- Repeat the ECG and compare with the first; consider right-sided and posterior leads if there is any doubt. Get a physician to review the ECG, not just the machine interpretation.
- Aspirin (unless contraindicated) per protocol, and sublingual GTN with BP monitoring, as ordered.
- IV access and bloods - troponin, FBC, U&E, glucose, lipids, clotting.
- Escalate to the ED physician immediately and document that the patient has ongoing ischaemic-sounding chest pain with a normal ECG.
- Continuous reassessment - symptoms, vital signs, rhythm, and repeat troponin at the appropriate interval per the local pathway.
The examiner wants the nurse to challenge the 'normal ECG = safe' assumption and to act on the clinical picture.
2. The patient's pain worsens and he becomes clammy and confused. What is happening and what should the nurse do?
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This is a deterioration - think evolving myocardial infarction, arrhythmia, or cardiogenic shock. New confusion and clamminess in a patient with chest pain suggest reduced cerebral and peripheral perfusion. The nurse should:
- Call for help immediately - activate the emergency/rapid response and get the ED physician to the bedside. Do not leave the patient.
- Recheck observations and rhythm - look for a new arrhythmia (e.g. ventricular tachycardia, bradycardia, heart block), hypotension, or hypoxia.
- Repeat the 12-lead ECG and show it to the physician.
- Support ABCs - oxygen if hypoxic (target 94-98%), position, IV access, and prepare for resuscitation.
- Prepare for definitive care - the local primary PCI pathway, or thrombolysis if PCI is not available within the target time and there are no contraindications. The nurse's role is to prepare, not to decide.
- Document everything - times, observations, interventions, and who was called.
Key learning point: a normal ECG at triage is a snapshot, not a verdict. The nurse who reassesses and escalates is the safety net. Confusion in a cardiac patient is a red flag, not a behaviour to be managed with reassurance.