How should I manage a patient with chronic chest pain who has a normal initial cardiac assessment?

When managing a patient with chronic chest pain who has had a normal initial cardiac assessment, the focus shifts to a detailed reassessment to determine if the pain is likely cardiac or due to other causes NICE CG95.

• Clinical Assessment: You should take a detailed clinical history, documenting the patient's age and sex, the characteristics of the pain (location, radiation, severity, duration, frequency, provoking and relieving factors), any associated symptoms like breathlessness, and any history of angina, myocardial infarction (MI), coronary revascularisation, other cardiovascular disease, or cardiovascular risk factors NICE CG95. A physical examination should be carried out to identify cardiovascular risk factors, signs of other cardiovascular disease, non-coronary causes of angina (e.g., severe aortic stenosis, cardiomyopathy), and to exclude other causes of chest pain NICE CG95.
• Assessing Pain Typicality: Assess the typicality of the chest pain NICE CG95. Anginal pain is defined as constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms, precipitated by physical exertion, and relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes NICE CG95. The presence of three of these features indicates typical angina, two indicates atypical angina, and one or none indicates non-anginal chest pain NICE CG95. Factors that make a diagnosis of stable angina more likely include age, male sex, and cardiovascular risk factors such as a history of smoking, diabetes, hypertension, dyslipidaemia, family history of premature coronary artery disease (CAD), or other established cardiovascular disease NICE CG95. Features that make stable angina unlikely include continuous or very prolonged pain, pain unrelated to activity, pain brought on by breathing in, or pain associated with symptoms like dizziness, palpitations, tingling, or difficulty swallowing NICE CG95. In such cases, consider causes of chest pain other than angina, such as gastrointestinal or musculoskeletal pain NICE CG95.
• Diagnostic Considerations: A normal resting 12-lead electrocardiogram (ECG) does not rule out a diagnosis of stable angina NICE CG95. Arrange blood tests to identify conditions that may exacerbate angina, such as anaemia NICE CG95. A chest X-ray should only be considered if other diagnoses, such as a lung tumour, are suspected NICE CG95.
• Management Pathways:
  • If stable angina cannot be excluded: If clinical assessment indicates typical or atypical angina, offer diagnostic testing NICE CG95. If the diagnosis of stable angina cannot be excluded in primary care, the patient should be routinely referred NICE CKS. Consider prescribing aspirin 75 mg daily until the diagnosis is confirmed NICE CKS.
  • If non-anginal chest pain: Unless clinical suspicion is raised by other history or risk factors, exclude a diagnosis of stable angina if the pain is non-anginal NICE CG95. Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment unless there are resting ECG ST-T changes or Q waves NICE CG95.
  • If ACS or stable angina is excluded but cardiovascular risk factors are present: Follow appropriate guidance, such as the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults NICE CG95.
  • If diagnosis is unclear or symptoms persist: If the cause of chest pain cannot be confidently established by clinical features alone, arrange appropriate investigations NICE CKS. Routinely refer the patient if the diagnosis is unclear, or if there is a clear diagnosis but persistent chest pain despite management in primary care NICE CKS.
  • Managing identified underlying causes: If a specific underlying cause is identified and the patient does not require admission or specialist referral, manage that cause (e.g., musculoskeletal chest pain with analgesia, non-specific or psychogenic chest pain with reassurance and management of anxiety/depression) NICE CKS.
  • Investigating other causes after specialist assessment: If significant CAD is not found during invasive coronary angiography or CT coronary angiography, or if reversible myocardial ischaemia is not found during non-invasive functional imaging, investigate other causes of chest pain NICE CG95. Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries NICE CG95.
• Patient Communication: Discuss any concerns the patient may have, including anxiety when the cause of chest pain is unknown, and correct any misinformation NICE CG95. Offer a clear explanation of the possible causes of their symptoms and any uncertainties NICE CG95. Clearly explain the options at every stage of investigation, making joint decisions and taking their preferences into account NICE CG95. Provide individual advice about seeking medical help if they experience further chest pain NICE CG95. If the chest pain is non-cardiac, explain this and refer for further investigation if appropriate NICE CG95.