Experience Summary

In this 360° experience, watch an A to E assessment on a 41-year-old patient named Adam.

Please note that these A to E assessments are intended for reflection and discussion. They are not perfect patient assessments, and investigation and management of these patients may change according to your local guidelines.

Case background

41-year-old male: Adam

PC: Chest pain

HPC: Sudden onset of central non-pleuritic chest pain. Started 2 hours ago while at work. Radiates to left arm and associated with some SOB. No palpitations. No N&V. No history of previous chest pains.

PMH: Hypertension

DH: Amlodipine. NKDA

FH: Father died of MI – age 46 years

SH: Builder / smoker – 1 pack/day for 23 years. Occasional Cannabis. Lives with wife

Acute Coronary Syndrome

Acute coronary syndrome (ACS) refers to a spectrum of conditions caused by sudden, reduced blood flow to the heart, most commonly due to rupture or erosion of an atherosclerotic plaque with subsequent thrombus formation. It encompasses unstable angina, non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Clinically, patients often present with chest pain or pressure, which may radiate to the arm, neck, or jaw, along with diaphoresis, dyspnea, nausea, or a sense of impending doom. Prompt evaluation includes ECG monitoring to detect ischemic changes and measurement of cardiac biomarkers—particularly high-sensitivity troponins—to identify myocardial injury.

Management begins with rapid stabilisation: oxygen if hypoxic, analgesia, and antiplatelet therapy. Aspirin is given immediately, followed by a P2Y12 inhibitor and anticoagulation. Beta-blockers, nitrates, and statins are initiated based on hemodynamic status and contraindications. STEMI requires urgent reperfusion, ideally through primary percutaneous coronary intervention (PCI), or fibrinolysis when PCI is unavailable. NSTEMI and unstable angina are managed with risk stratification tools to guide timing of invasive evaluation; high-risk patients typically undergo early angiography.

Long-term management focuses on secondary prevention—high-intensity statins, dual antiplatelet therapy, lifestyle modification, blood pressure and diabetes control—to reduce recurrent events and improve survival.

Discussion points

• What was good about the clinicians A to E assessment?
• What could the clinician improve about their A to E assessment?
• How was the clinician’s communication throughout the A to E assessment?
• How did the clinician make the decision to treat the patient as an NSTEMI?
• What is your local management for ACS?
• What would be the next steps in the management of this patient?

Learning Outcomes

1. Observe an ABCDE assessment for a critically unwell patient.
2. Increase understanding of ECG interpretation.
3. Increase understanding of the recognition of ACS.
4. Understand the management of ACS.
5. Understand the use of the ALS algorithm for adult tachycardia.

External Resources

• Acute coronary syndromes - NICE guideline
• Adult tachycardia algorithm - Resuscitation Council