Resting 12-lead ECG in the assessment of acute possible cardiac chest pain

If patient presents with acute possible cardiac chest pain then NICE suggest:

• take a resting 12-lead ECG as soon as possible. When people are referred, send the results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital.
• follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor
• if unstable angina/NSTEMI suggested by an ECG showing regional ST-segment depression or deep T wave inversion then manage as unstable angina/NSTEMI until a firm diagnosis is made. Continue to monitor
• even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider managing as unstable angina/NSTEMI if these conditions are likely. Continue to monitor
• do not exclude an ACS when people have a normal resting 12-lead ECG
• if a diagnosis of ACS is in doubt, consider:
  • taking serial resting 12-lead ECGs
  • reviewing previous resting 12-lead ECGs
  • recording additional ECG leads. Use clinical judgement to decide how often this should be done. Note that the results may not be conclusive
• obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated interpretation
• if clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life-threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor

Reference:

• 1) NICE (March 2010). Chest pain of recent onset