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

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 ¹.
  • 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 ¹. 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 ¹. Do not use response to glyceryl trinitrate (GTN) to make a diagnosis ¹.
  • 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 ¹,². Also, consider emergency referral if pain has resolved but there are signs of complications like pulmonary oedema ¹.
  • 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 ¹,².
  • 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) ². Give aspirin 300 mg (unless allergic) and send a written record with the patient ². Take a resting 12-lead ECG and send it with the patient, ensuring this does not delay transfer ². 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 ².
  • Physiological Assessment: Measure blood pressure, pulse rate, temperature, breathing rate, oxygen saturation, and level of consciousness ².
• 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 ¹.
  • 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 ¹.
  • 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) ¹.
    • Atypical Angina: Two of the above features present ¹.
    • Non-Anginal Chest Pain: One or none of the above features present ¹.
  • 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) ¹.
  • 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 ¹. Consider gastrointestinal or musculoskeletal causes in these cases ¹.
  • Diagnostic Testing: If clinical assessment indicates typical or atypical angina, offer diagnostic testing ¹. If stable angina cannot be excluded by clinical assessment alone, take a resting 12-lead ECG as soon as possible ¹. A normal resting 12-lead ECG does not rule out stable angina ¹. Do not offer diagnostic testing for non-anginal chest pain unless there are resting ECG ST-T changes or Q waves ¹.
  • Blood Tests: Arrange blood tests to identify conditions that exacerbate angina, such as anaemia ¹.
  • Chest X-ray: Only consider a chest X-ray if other diagnoses, such as a lung tumour, are suspected ¹.
  • Referral for Stable Angina: Refer routinely if suspected stable angina where the diagnosis cannot be excluded in primary care ². Consider prescribing aspirin (e.g., 75 mg daily) until diagnosis is confirmed ².
• 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 ¹.
  • 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 ².
  • 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 ².
• General Patient Communication
  • Discuss any concerns the patient (and family/carer) may have, including anxiety, and correct misinformation ¹.
  • Offer a clear explanation of possible causes and uncertainties ¹.
  • Explain options at every stage of investigation, making joint decisions and taking account of preferences ¹. Provide information about proposed investigations using jargon-free language, including purpose, benefits, limitations, duration, discomfort, invasiveness, and risks ¹.
  • Address any physical or learning difficulties, sight/hearing problems, or language barriers ¹.
  • Provide individual advice about seeking medical help for further chest pain ¹.