Mr Barker’s lower chest and epigastric discomfort gets worse and worse. His friends are concerned and call an ambulance. He is brought directly to Accident & Emergency.

You are now taking the history in the resuscitation room of the emergency department. (In practice if acute myocardial infarction is suspected the history you take will be very brief since it is important to achieve reperfusion as quickly as possible and this will be guided by the appearance of the ECG).

• The episodes of lower sternal and epigastric discomfort were initially only on exertion. However, in the last 3 days the discomfort has been occurring with trivial exercise and also at rest, particularly at times of psychological stress.

• He describes the discomfort in extremely vague terms. He is unable to localise the pain but in his description clenches his fist and presses it against his lower sternum.

• Until today the longest episode of chest discomfort was 10 minutes. He now has had 40 minutes of continuous chest discomfort, which he says is becoming more and more severe. In addition, he is becoming more breathless and his friend noticed that he had become cold and clammy during his journey from the building site to the hospital.

Apart from these symptoms the patient has been well. However, on direct questioning, in addition to the smoking, you also obtain a strong family history of ischaemic heart disease with an older brother and his father dying before the age of 55 of acute myocardial infarction.