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Lesson

ACS Without Chest Pain

12 min Cardiac & ECG Skip to quiz

Objective: Treat shortness of breath, fatigue, nausea, or upper-belly pain as possible ACS until the 12-lead and the story say otherwise. Do this especially for women, older adults, and people with diabetes.

Why this matters

Chest discomfort is still the most common symptom of a heart attack. It is not the only one. ACS means acute coronary syndrome, a heart-attack workup. Women more often also have symptoms that are not chest pain. Older adults and people with diabetes may have shortness of breath, fatigue, nausea, or upper-belly pain with little or no chest pain.

Get a 12-lead when ACS is possible, within about 10 minutes of first medical contact. If you wait for the words “chest pain,” you will miss people who needed a PCI hospital. PCI means the cath lab that opens a blocked artery.

Key points
  • Start with the 12-lead when the story fits. Do not wait for the patient to say “pain.”
  • Check the risk. Older adults, women, people with diabetes, known coronary artery disease, and kidney disease still have ACS. Age and diabetes do not rule it out.
  • One normal 12-lead does not close the case. If symptoms continue, get another tracing. See the serial 12-lead lesson.

Clinical sequence

  1. Protect the airway, breathing, and circulation first. If the patient is unstable, treat that first. ACS care happens with that work, not instead of it. Give oxygen if the sat is under about 90%. Do not put a non-rebreather on a patient who is already near 98%.
  2. If ACS is possible, including symptoms other than chest pain, get a 12-lead as soon as it will not delay life-saving care. Aim for about 10 minutes from first medical contact.
  3. Give aspirin and choose the hospital only per protocol. Give nitro only after you have checked the right ventricle and the blood pressure.
  4. If the first tracing does not show the diagnosis and the patient still looks like ACS, get another 12-lead. Tell the hospital the symptoms. Do not report only “no chest pain.”

Teaching points

  • Most common symptom other than chest pain: new unexplained shortness of breath with exertion. That finding is common, not rare.
  • Women: chest symptoms are still common. They more often also report jaw, back, or neck discomfort, nausea, fatigue, or shortness of breath. Do not call it anxiety because the patient is a woman.
  • Diabetes and older adults: the picture is more often quiet or unusual. Weakness, confusion, vomiting alone, or “I just don’t feel right,” plus risk factors, means get a 12-lead.
  • Use the 12-lead, not a rhythm strip. Lead II is not a substitute. Transmit the tracing. If the pattern is concerning, ask for a PCI-capable hospital.
Verbalize
  • This is an ACS story even without chest pain.
  • I am getting the 12-lead now.
  • The symptom may be shortness of breath, fatigue, or nausea.
  • I am transmitting the 12-lead.

Common errors

  • Skipping the 12-lead because the patient denied pain.
  • Calling an older woman’s nausea a stomach problem without a tracing.
  • Stopping after one normal strip and a refusal without writing down the other symptoms.

Practice

One-minute check

Partner: 78-year-old woman with diabetes, sudden fatigue and nausea, no chest pain, and pale. Say what you do in the first 60 seconds. Then the 12-lead is subtle. What do you tell the hospital?

Related: 12-Lead STEMI Recognition, STEMI Equivalents.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. When ACS is suspected — including anginal equivalents — acquire a 12-lead:
2. The most common anginal equivalent taught in ACS is:
3. Women with ACS, compared with men, are more likely to:
4. An older adult with diabetes, sudden weakness, and sweating, but no chest pain, should:
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