Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin continued

Percentage of people estimated to have coronary artery disease according to typicality of symptoms, age, sex and risk factors*

Age (Years)	Non-anginal chest pain				Atypical angina				Typical angina
	Men		Women		Men		Women		Men		Women
	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi	Lo	Hi
35	3	35	1	19	8	59	2	39	30	88	10	78
45	9	47	2	22	21	70	5	43	51	92	20	79
55	23	59	4	25	45	79	10	47	80	95	38	82
65	49	69	9	29	71	86	20	51	93	97	56	84
For men older than 70 with atypical or typical symptoms, assume an estimate > 90%. For women older than 70, assume an estimate of 61–90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed
Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD). Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre). Lo = Low risk = none of these three. The shaded area represents people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely. Note: These results are likely to overestimate CAD in primary care populations.If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table
*Adapted from Pryor DB, Shaw L, McCants CB et al. (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Annals of Internal Medicine 118 (2): 81–90.

People presenting with acute chest pain

Check for a suspected ACS

• Check immediately if chest pain is current, or when the last episode was, particularly if in the last 12 hours
• Check if the chest pain may be cardiac. Consider:
  • history of the pain
  • any cardiovascular risk factors
  • history of ischaemic heart disease and any previous treatment
  • previous investigations for chest pain
• Check if any of the following symptoms of ischaemia are present. These may indicate an ACS:
  • pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
  • chest pain with nausea and vomiting, marked sweating or breathlessness (or a combination of these), or with haemodynamic instability
  • new onset chest pain, or abrupt deterioration in stable angina, with recurrent pain occurring frequently with little or no exertion and often lasting longer than 15 minutes
• Central chest pain may not be the main symptom
• Do not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS
• Do not assess symptoms of an ACS differently in men and women or among different ethnic groups
• Advise people about seeking medical help if they have further chest pain
• If the chest pain is non-cardiac, explain this to the person and refer for further investigation if appropriate
• If the chest pain is suspected to be an ACS follow the pathway on the next page

Immediate management of a suspected ACS

• In the order appropriate to the circumstances, offer:
  • pain relief (GTN and/or an intravenous opioid)
  • a single loading dose of 300 mg aspirin unless the person is allergic. Send a written record with the person if given before arriving at hospital. Only offer other antiplatelet agents^† in hospital
  • a resting 12-lead ECG. Send to the hospital before the person arrives if possible
  • other therapeutic interventions^† as necessary
  • pulse oximetry, ideally before hospital admission. Offer oxygen:
    • if oxygen saturation (SpO₂) is less than 94% with no risk of hypercapnic respiratory failure. Aim for SpO₂ of 94–98%
    • to people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure. Aim for SpO₂ of 88–92% until blood gas analysis is available
  • monitoring

Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin continued

Referral to hospital

Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin continued

People presenting with stable chest pain

• Angina can be diagnosed based on clinical assessment alone or clinical assessment plus diagnostic testing
• Manage risk factors for cardiovascular disease‡ if chest pain is not stable angina

Clinical history

• Record:
  • age and sex
  • pain characteristics, factors provoking and relieving the pain
  • associated symptoms
  • history of cardiovascular disease
  • cardiovascular risk factors

Physical examination

• Identify cardiovascular risk factors
• Look for signs of other cardiovascular disease
• Exclude:
  • non-coronary causes of angina (e.g. severe aortic stenosis, cardiomyopathy)
  • other causes of chest pain

Features of stable angina

• Anginal pain is:
  • constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
  • precipitated by physical exertion
  • relieved by rest or GTN in about 5 minutes
• People with typical angina have all the above anginal pain features, people with atypical angina have two of the features and people with non-anginal chest pain have one or none of the features
• Do not define typical and atypical features of anginal and non-anginal chest pain differently in men and women or among ethnic groups
• Factors making stable angina more likely:
  • increasing age
  • whether the person is male
  • cardiovascular risk factors
  • a history of established CAD (e.g. previous MI, coronary revascularisation)
• Stable angina is unlikely if the pain is:
  • continuous or very prolonged and/or
  • unrelated to activity and/or
  • brought on by breathing in and/or
  • associated with dizziness, palpitations, tingling or difficulty swallowing

Resting 12-lead ECG testing

• Do not rule out stable angina based on a normal ECG
• Consider ECG changes with people’s clinical history and risk factors. Changes consistent with CAD which may indicate ischaemia or previous infarction include:
  • pathological Q waves in particular
  • LBBB
  • ST-segment and T wave abnormalities (e.g. flattening or inversion).Results may not be conclusive

 

* See the full guideline and the NICE guideline at www.nice.org.uk/guidance/CG95

^† Follow 'Unstable angina and NSTEMI' (NICE clinical guideline 94) or local protocols for ST-segment-elevation myocardial infarction (STEMI)

^‡ Follow appropriate guidance, e.g. 'Hypertension' (NICE clinical guideline 34) or 'Lipid modification' (NICE clinical guideline 67).

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG95

National Institute for Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin.. March 2010