Print this page. Four columns in time: the first minutes, the hospital stay, the discharge, and the months after. Each line is something the UK or US guideline says should happen; a blank box is a question to ask. The rhythm card at the bottom is for atrial fibrillation.
The first minutes
| Done | What should happen |
|---|---|
| ☐ | 999 called and "heart attack" or "chest pain" said; not driven in |
| ☐ | Sitting, still; aspirin 300 mg chewed unless allergic; own GTN if prescribed (two doses five minutes apart, then 999) |
| ☐ | Time the pain started written down as a clock time; medicine list gathered; door unlocked |
| ☐ | Ambulance ECG within ten minutes; STEMI pre-alerted and taken directly to the heart attack centre |
In hospital
| Done | What should happen | Ref. |
|---|---|---|
| ☐ | STEMI: artery opened by PCI within 120 minutes of the diagnostic ECG, via the wrist; or clot-busting drug within 30 minutes and angiography within 24 hours if PCI could not be reached in time | NG185 |
| ☐ | Not STEMI: troponin on a timed pathway (0 and 1–3 hours); GRACE score recorded | DG40; NG185 |
| ☐ | NSTEMI at intermediate risk or above: angiography within 72 hours; immediately if unstable | NG185 |
| ☐ | Aspirin, a second antiplatelet and an anticoagulant started; oxygen only if saturations low | NG185 |
| ☐ | High-intensity statin started; lipids taken within 24 hours; HbA1c, kidney function, thyroid function, full blood count | NG185; NG238 |
| ☐ | ACE inhibitor started once stable; beta-blocker by ejection fraction | NG185 |
| ☐ | Continuous rhythm monitoring for at least 24–48 hours | NG185 |
| ☐ | Echocardiogram before discharge; ejection fraction written on the letter | NG185 |
| ☐ | Clean arteries: cardiac MRI arranged, and SCAD, spasm, takotsubo and myocarditis considered by name | ESC 2023; AHA 2025 |
| ☐ | Cardiogenic shock: culprit artery opened; mechanical support discussed with the shock team | AHA 2025 |
| ☐ | New heart block: reversible causes checked (drugs, potassium, thyroid, Lyme, inferior MI) before a permanent pacemaker | ESC 2021 |
At discharge
| Done | What should happen | Ref. |
|---|---|---|
| ☐ | The named diagnosis on the letter: STEMI, NSTEMI, type 2, MINOCA, SCAD, takotsubo, myocarditis, pericarditis | — |
| ☐ | Every drug with its duration; the second antiplatelet's stop date; the GTN rule | NG185 |
| ☐ | Cardiac rehabilitation referral made, first contact within days | NG185; AHA 2025 |
| ☐ | Driving, flying, work and sex advice given in writing; the DVLA rule that applies | DVLA |
| ☐ | Smoking cessation started; anti-inflammatory painkillers stopped | NG185 |
| ☐ | A follow-up appointment with a date; a home blood pressure monitor | — |
| ☐ | Under 60, or a relative with an early heart attack: familial hypercholesterolaemia assessment; lipoprotein(a) once | CG71; HEART UK |
| ☐ | Arrest or dangerous rhythm without a cause: inherited cardiac conditions referral; family screening discussed | ESC 2022 |
The months after
| Done | What should happen | Ref. |
|---|---|---|
| ☐ | Rehabilitation attended | NG185 |
| ☐ | Lipids rechecked on treatment at 2–3 months against LDL 2.0 / non-HDL 2.6 (UK); next drug added if not met | NG238 |
| ☐ | Kidney function and potassium after each ACE-inhibitor step | NG185 |
| ☐ | Repeat echocardiogram at 6–12 weeks if the pump was weakened; defibrillator decision at 40–90 days if ejection fraction still 35% or less | TA314 |
| ☐ | Beta-blocker reviewed at the first follow-up if the pump is normal | 2025 evidence |
| ☐ | Mood screened; sleep apnoea asked about | NG185 |
| ☐ | Second antiplatelet stopped at 12 months, or continued for a stated reason | NG185 |
| ☐ | Flu vaccination each autumn | IAMI |
| ☐ | Annual review: blood pressure, lipids, HbA1c, kidney function, weight, smoking, medicine review | — |
The atrial fibrillation card
| Stroke-risk score (one point each unless stated) | What should happen |
|---|---|
| Heart failure | Score 2 or more: anticoagulation offered (UK: CHA2DS2-VASc; Europe: CHA2DS2-VA without the sex point) |
| Hypertension | Score 1: anticoagulation considered |
| Age 75 or over (2 points) | A DOAC, not warfarin, not aspirin |
| Diabetes | Bleeding risk scored to fix the fixable, not to withhold |
| Previous stroke, TIA or embolism (2 points) | Rate control started; rhythm control or ablation discussed if symptoms persist, the AF is new, or the pump is weak |
| Vascular disease | Alcohol, weight, blood pressure, sleep apnoea and diabetes addressed |
| Age 65–74 | Thyroid function and an echocardiogram done |
| Female sex (UK score only) | Anticoagulation continues after any rhythm treatment if the score warrants it |
NG185 is NICE's acute coronary syndromes guideline; NG196 its atrial fibrillation guideline; NG238 its lipid guideline; DG40 its troponin diagnostics guidance; CG71 its familial hypercholesterolaemia guideline; TA314 its defibrillator appraisal. "AHA 2025" is the American acute coronary syndromes guideline; "ESC" the European Society of Cardiology.