How should I assess and manage a patient presenting with chest pain in a primary care setting?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 14 August 2025Updated: 14 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

When assessing and managing a patient presenting with chest pain in a primary care setting, a systematic approach is crucial, distinguishing between acute and stable presentations.

  • Initial Assessment and Referral for Acute Chest Pain (Suspected ACS)
    • Immediate Check: Determine if the patient currently has chest pain or when their last episode was, especially if within the last 12 hours .
    • Assess for ACS Symptoms: Look for pain in the chest and/or other areas (arms, back, jaw) lasting longer than 15 minutes, or chest pain associated with nausea, vomiting, marked sweating, breathlessness, or hemodynamic instability . New onset chest pain or abrupt deterioration of stable angina with frequent, prolonged episodes (over 15 minutes) with little or no exertion also suggest ACS . Do not use response to glyceryl trinitrate (GTN) to make a diagnosis .
    • Emergency Hospital Referral: Refer patients to hospital as an emergency if an Acute Coronary Syndrome (ACS) is suspected and they currently have chest pain, or if they are pain-free but had chest pain in the last 12 hours and a resting 12-lead ECG is abnormal or not available ,. Also, consider emergency referral if pain has resolved but there are signs of complications like pulmonary oedema .
    • Urgent Same-Day Assessment: Refer for urgent same-day assessment if ACS is suspected and they had chest pain in the last 12 hours (now pain-free with normal resting 12-lead ECG and no complications), or if the last episode of pain was 12 to 72 hours ago ,.
    • Pre-hospital Management (if ACS suspected): Treat pain with GTN and/or an opioid (e.g., intravenous diamorphine 2.5 mg to 5.0 mg slowly over 5 minutes) . Give aspirin 300 mg (unless allergic) and send a written record with the patient . Take a resting 12-lead ECG and send it with the patient, ensuring this does not delay transfer . Do not routinely administer oxygen unless SpO2 is less than 94% (target 94-98%) or 88-92% for those at risk of hypercapnic respiratory failure .
    • Physiological Assessment: Measure blood pressure, pulse rate, temperature, breathing rate, oxygen saturation, and level of consciousness .
  • Assessment and Management for Stable Chest Pain (Suspected Stable Angina)
    • Detailed Clinical History: Document age, sex, pain characteristics (location, radiation, severity, duration, frequency, provoking/relieving factors), associated symptoms (e.g., breathlessness), history of angina, MI, revascularisation, other cardiovascular disease, and cardiovascular risk factors .
    • Physical Examination: Identify cardiovascular risk factors, signs of other cardiovascular disease, non-coronary causes of angina (e.g., severe aortic stenosis), and exclude other causes of chest pain .
    • Assess Typicality of Pain:
      • Typical Angina: Constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms; precipitated by physical exertion; relieved by rest or GTN within about 5 minutes (all three features present) .
      • Atypical Angina: Two of the above features present .
      • Non-Anginal Chest Pain: One or none of the above features present .
    • Factors Increasing Likelihood of Angina: Age, male sex, and cardiovascular risk factors (smoking, diabetes, hypertension, dyslipidaemia, family history of premature CAD, other cardiovascular disease, history of established CAD) .
    • Factors Making Angina Unlikely: Continuous or very prolonged pain, unrelated to activity, brought on by breathing in, or associated with dizziness, palpitations, tingling, or difficulty swallowing . Consider gastrointestinal or musculoskeletal causes in these cases .
    • Diagnostic Testing: If clinical assessment indicates typical or atypical angina, offer diagnostic testing . If stable angina cannot be excluded by clinical assessment alone, take a resting 12-lead ECG as soon as possible . A normal resting 12-lead ECG does not rule out stable angina . Do not offer diagnostic testing for non-anginal chest pain unless there are resting ECG ST-T changes or Q waves .
    • Blood Tests: Arrange blood tests to identify conditions that exacerbate angina, such as anaemia .
    • Chest X-ray: Only consider a chest X-ray if other diagnoses, such as a lung tumour, are suspected .
    • Referral for Stable Angina: Refer routinely if suspected stable angina where the diagnosis cannot be excluded in primary care . Consider prescribing aspirin (e.g., 75 mg daily) until diagnosis is confirmed .
  • Management of Non-Cardiac Chest Pain
    • Exclusion: Exclude a diagnosis of stable angina if clinical assessment indicates non-anginal chest pain and there are no other aspects of history or risk factors raising clinical suspicion .
    • Manage Underlying Cause: If not requiring hospital admission or specialist referral, manage the underlying cause, such as musculoskeletal chest pain (analgesia), non-specific or psychogenic chest pain (reassurance, anxiety management), dyspepsia, community-acquired pneumonia, or shingles .
    • Referral for Unclear/Persistent Pain: Refer routinely if the cause of chest pain is unclear, or if there is a clear diagnosis but symptoms persist despite primary care management .
  • General Patient Communication
    • Discuss any concerns the patient (and family/carer) may have, including anxiety, and correct misinformation .
    • Offer a clear explanation of possible causes and uncertainties .
    • Explain options at every stage of investigation, making joint decisions and taking account of preferences . Provide information about proposed investigations using jargon-free language, including purpose, benefits, limitations, duration, discomfort, invasiveness, and risks .
    • Address any physical or learning difficulties, sight/hearing problems, or language barriers .
    • Provide individual advice about seeking medical help for further chest pain .

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