You are given a standby call by the local ambulance service for a 25 year old patient with severe chest pain. Ambulance control tells you that the patient has ECG changes.

You immediately think - " Cocaine" - but this probably reflects your cynicism and on this occasion will prove to be incorrect.

When he arrives you see a 25 year old well looking 25 year old man. He is complaining of quite severe central chest pain with some pain in his left shoulder. His pain started at approximately 4am and is described as a heavy dullness. He was able to get back to sleep, but when he woke later the pain was still there. It was not associated with sweating, nor shortness of breath.

He is previously fit and well, is on no medication and is a non-smoker. His father was diagnosed as having angina at the age of 55.

Again, he denies the use of cocaine - and you believe him (though it was a good thought to have).