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ISCHAEMIC HEART DISEASE (IHD): DIAGNOSIS• Angina due to IHD is typically central burning or crushing chest pain that may spread to jaw, left shoulder, down left arm and is suggested by:--Pain lasting for 5 minutes or less, usually brought on by exercise, effort or anxiety and relieved by rest and--Pain occurring consistently at same distance or level of effort and--9 out of 10 times occurring with effort and 1 out of 10 times at rest.Dr • A doctor must make or confirm the diagnosis of ischaemic heart disease.Recognise the patient with possible unstable angina or heart attack needing urgent attention:• Chest pain at rest or minimal effort.• Chest pain lasting more than 10 minutes.• If known IHD: pain worsening, lasting longer than usual, not relieved by sublingual nitrates.• Patient may be sweating, nauseous, vomiting, breathless.• ECG may show ST segment depression or elevation, but a normal ECG does not exclude diagnosis of angina or heart attack.• BP < 90/60Arrange urgent ambulance transfer to hospital and manage as follows:• Give 40% face mask oxygen.• If BP < 90/60 give 200ml sodium chloride 0.9% IV.• Give aspirin 150mg single dose.• Isosorbide dinitrate sublingual 5mg every 5-10 minutes until pain relieved to a maximum of 5 tablets.• Morphine 15mg diluted with 14ml of water for injection or sodium chloride 0.9%. Give 1ml/min IV until pain relieved.• Doctor to confirm unstable angina or heart attack and assess patient for streptokinase:--Give if within 6 hours of onset of pain and ST segment elevation above baseline or new LBBB on ECG.--Avoid if active bleeding or known bleeding disorder, stroke within the last 6 months or any previous haemorrhagic stroke, gastrointestinal bleeding within the last 3months or peptic ulcer, streptokinase given within the past year or known allergy to it, or recent major trauma, surgery or head injury.--Doctor to give streptokinase 1.5 million IU diluted in 100ml dextrose 5% or sodium chloride 0.9% IV over 30–60 minutes.• Refer urgently to hospital.For routine care of the patient with IHD 78.77