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Test to do in heart attack

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"myocardial infarction" AND diagnosis

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heart attack diagnosis tests ECG troponin emergency official guideline

For a suspected heart attack (myocardial infarction), tests are done urgently in an emergency department:
  1. 12-lead ECG/EKG: first and immediate test. It can show STEMI, ischemic changes, rhythm problems, or previous infarction.
  2. High-sensitivity cardiac troponin blood test: the key blood test for heart-muscle injury. It is usually repeated after 1-3 hours to check for a rise or fall.
  3. Vital signs and clinical assessment: blood pressure, pulse, oxygen level, symptoms, examination, and medical history.
  4. Echocardiogram: ultrasound of the heart, looking for weak pumping or a new regional wall-motion abnormality.
  5. Coronary angiography: dye test to identify a blocked coronary artery. It is urgent in STEMI and many high-risk cases, and can be followed immediately by angioplasty/stenting.
  6. Chest X-ray: helps exclude other causes of chest pain or breathlessness and detects complications such as heart failure.
  7. Other blood tests: complete blood count, glucose, kidney function, electrolytes, clotting tests, and lipid profile. CK-MB may sometimes be used, but troponin is the preferred marker.
Heart attack diagnosis is based on symptoms or evidence of ischemia plus a changing elevated troponin, supported by ECG or imaging findings. Troponin can be high for reasons other than a heart attack, so it must be interpreted with the ECG and clinical picture. The American Heart Association overview lists ECG, troponin, echocardiography, angiography, CT, and MRI among diagnostic tests.
If chest pressure/pain, sweating, shortness of breath, nausea, fainting, or pain spreading to the arm, jaw, back, or upper abdomen is happening now, call emergency services immediately. Do not drive yourself or wait for outpatient tests.
  • Rosen's Emergency Medicine Concepts and Clinical Practice, Acute Myocardial Infarction

Find the latest guidelines for heart attack diagnosis

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2025 ACC AHA acute coronary syndromes guideline diagnosis ECG troponin official guideline

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2023 ESC Guidelines acute coronary syndromes diagnosis ECG high sensitivity troponin official

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"acute coronary syndrome" AND "practice guideline"

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2026 Fifth Universal Definition of Myocardial Infarction diagnosis troponin ECG official ACC ESC

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PMID: 40014670

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https://www.escardio.org/guidelines/clinical-practice-guidel…

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https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309

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PMID: 41693087

Latest heart attack diagnosis guidance

The newest international standard is the Fifth Universal Definition of Myocardial Infarction, 2026, issued jointly by the ESC, ACC, AHA, and World Heart Federation. It replaces the 2018 definition. The ESC 2026 statement emphasizes sex-specific troponin thresholds, serial testing, accelerated high-sensitivity troponin pathways, and imaging to establish the cause.
The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Acute Coronary Syndromes guideline remains the newest major US management guideline for suspected ACS, including STEMI, NSTEMI, and unstable angina. It supersedes earlier separate US STEMI and NSTEMI guidelines. [Practice Guideline . Tier 6 . 2025] Rao et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for Acute Coronary Syndromes. Circulation. PMID: 40014670. An erratum is listed for this article, PMID: 41212941.

Core diagnostic approach

A heart attack, or myocardial infarction (MI), requires both:
  1. Acute myocardial injury
    • Cardiac troponin above the assay's 99th-percentile upper reference limit, and
    • A significant rise and/or fall on serial blood testing.
  2. Clinical evidence that acute ischemia caused the injury, such as at least one of:
    • Symptoms compatible with ischemia, for example chest pressure, breathlessness, sweating, nausea, jaw/arm/back discomfort
    • New ischemic ECG changes
    • Development of pathological Q waves
    • Imaging showing new loss of viable heart muscle or a new regional wall-motion abnormality
    • Coronary thrombus identified by angiography or autopsy
This distinction matters: a raised troponin alone is myocardial injury, not automatically a heart attack. Kidney disease, severe infection, fast arrhythmia, pulmonary embolism, heart failure, and other conditions can raise troponin.

Tests recommended immediately for suspected heart attack

TestRole
12-lead ECGObtain immediately and repeat if symptoms continue or the first ECG is non-diagnostic. Identifies ST-elevation and other ischemic or occlusion patterns.
High-sensitivity cardiac troponin, serial testsPreferred biomarker. Use a validated local 0/1-hour, 0/2-hour, or other accelerated pathway, not a single isolated result.
Clinical assessmentSymptoms, onset time, risk factors, examination, blood pressure, pulse, oxygen saturation, and alternative diagnoses.
EchocardiographyDetects new regional wall-motion abnormality, reduced ventricular function, and mechanical complications. It is especially useful when ECG or troponin findings are uncertain.
Coronary angiographyDefines coronary anatomy and identifies a culprit blockage. It is urgent when STEMI or an occlusion pattern is suspected.
Coronary CT angiography or cardiac MRISelective tests when the diagnosis or cause remains unclear. Cardiac MRI can differentiate infarction from myocarditis, Takotsubo syndrome, and other myocardial injury.

What is new or emphasized in 2026

  • Sex-specific troponin thresholds are incorporated to reduce underdiagnosis, especially in women.
  • High-sensitivity troponin accelerated diagnostic pathways are formally emphasized.
  • Imaging is encouraged to determine the underlying cause of MI.
  • MI is now classified clinically as:
    1. Primary MI: spontaneous coronary event, commonly plaque disruption with thrombosis.
    2. Secondary MI: oxygen supply-demand imbalance, without primary acute coronary thrombosis.
    3. Procedure-related MI.
  • The updated definition also provides clearer criteria for silent or unrecognized MI and reframes MINOCA as a working diagnostic category that requires further evaluation. The ACC summary of the 2026 update describes these changes.
The 2023 ESC ACS guideline remains a major ACS care reference internationally, but the 2026 Universal Definition is the latest authority specifically for defining and diagnosing MI.
If chest pain, pressure, acute breathlessness, cold sweating, fainting, or pain radiating to the jaw, back, or arm is occurring now, seek emergency help immediately. Diagnosis must not be delayed for outpatient testing.
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