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When evaluating a patient with a complaint of chest pain, EMS professionals should begin by assessing the patient’s stability and then obtain a basic clinical history and examination. Early in the assessment, an EMS clinician should apply a cardiac monitor to rapidly identify dysrhythmias, perform a diagnostic 12‐lead ECG, and administer specific treatment depending on the results of the initial evaluation. Because only a small minority of the patients with chest pain actually have ACS, maintaining vigilance in this assessment and diagnostic routine can be difficult [8].

Complete accuracy in the diagnosis of chest pain is not always possible in any setting, not even in the hospital [9]. The prehospital clinician should not expect to diagnose a patient with a complaint of chest pain definitively. A careful history can lead the clinician to a correct “category” of diagnosis much of the time. As a general approach, the patient should be treated as if he or she has the most likely serious illness consistent with the signs and symptoms.

Discomfort due to cardiac ischemia is usually, but not always, substernal and may radiate to the shoulder, either arm, both arms, upper abdomen, back, or jaw [9, 10]. Other symptoms such as nausea and diaphoresis are commonly present but do not accurately predict the presence or absence of ACS. Cardiac disease is most often seen beginning in middle‐aged men and older women. However, even younger adults under the age of 40 with chest pain but no cardiac risk factors and a normal ECG have a 1%–2% risk of ACS [11]. Taking a focused history using the “PQRST method” can be helpful (Box 9.1).