oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
It is often difficult to be certain as to whether chest pain is of cardiac or non-cardiac cause. A full history should be taken from the patient to assess the need for either immediate hospital admission or urgent hospital referral. Any doubt should lead to referral to secondary care for further assessment, either to the local chest pain clinic or urgent hospital admission.
Rapid access chest pain clinics have improved diagnosis of incident angina in those with high risk of cardiovascular disease, but misdiagnosis rates are high and a recent study showed that a third of all cardiac events in subsequent follow-up occurred in those diagnosed with non-cardiac chest pain. Experience may play some role but evidence suggests that increasing physician experience decreases threshold for admission without an increase in diagnostic accuracy. GPs tend to use their previous experience of a patient's behaviour in comparison with the current consultation as well as textbook criteria to diagnose chest pain.
Assessment for possible acute coronary syndrome
- Consider the history of the pain, any cardiovascular risk factors, history of ischaemic heart disease and any previous treatment, and previous investigations for chest pain.
- Symptoms that may indicate acute coronary syndrome (ACS) include:
- Pain in the chest and/or other areas (eg the arms, back or jaw) lasting longer than 15 minutes.
- Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or 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.
- The response to glyceryl trinitrate (GTN) should not be used to make a diagnosis and symptoms should not be assessed differently in men and women or among different ethnic groups.
- Patients with pre-existing angina should be advised that when an attack of angina occurs, they should:
- Stop what they are doing and rest.
- Use GTN spray or tablets as instructed.
- Take a second dose of GTN after 5 minutes if the pain has not eased.
- Take a third dose of GTN after a further 5 minutes if the pain has still not eased.
- Call 999 for an ambulance if the pain has not eased after another 5 minutes (ie 15 minutes after onset of pain), or earlier if the pain is intensifying or the person is unwell.
- 20-40% of all medical admissions are for acute chest pain.
- Coronary heart disease remains the principal cause of death in the UK and a fifth of these deaths occurs below retirement age.
- The main risk factors are smoking, hypertension, hyperlipidaemia, diabetes and obesity.
A full cardiovascular assessment is essential (see separate article Cardiovascular History and Examination).
- Chest pain due to cardiac ischaemia typically tends to be retrosternal or epigastric, tight and crushing in quality, and may radiate to the arms, shoulders, neck or jaw.
- Aortic dissection tends to cause pain with a tearing quality; pericarditis and pulmonary pain tend to be worse on inspiration (pleuritic) and oesophageal reflux pain has a burning quality.
- Cardiac ischaemia pain tends to be retrosternal.
- Stable angina is likely if chest discomfort or breathlessness is associated with effort, emotion, food or cold weather, symptoms are relieved by rest and/or glyceryl trinitrate (GTN) and one or more risk factors for coronary artery disease are present.
- In patients with acute coronary syndrome:
- Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue, and/or palpitations.
- Shortness of breath may be the main symptom of cardiac ischaemia, associated with angina pain, or a symptom of heart failure.
- Atypical presentations are common (especially in women, older men, people with diabetes, and people from ethnic minorities), eg abdominal discomfort or jaw pain; elderly patients may present with altered mental state.
- The assessment of any patient with possible cardiac chest pain should include smoking history, past history of cardiovascular disease and comorbidities, especially diabetes, hypertension and hyperlipidaemia.
- Many patients will have entirely normal examination findings. However, a thorough cardiovascular examination is essential.
- Always check pulse rate and rhythm, blood pressure, auscultate heart sounds (ensure no murmurs, eg aortic stenosis can present with angina) and chest (to exclude signs of heart failure).
- Consider findings suggesting non-cardiac chest pain, eg tenderness of the chest wall, epigastric tenderness due to a peptic ulcer, and focal lung signs associated with pneumonia.
Differential diagnosis of chest pain
The main causes of chest pain include:
- Angina, acute coronary syndrome (ACS) (including myocardial infarction).
- Acute pericarditis.
- Pneumonia, pulmonary embolus, pneumothorax.
- Gastro-oesophageal reflux, oesophageal spasm.
- Peptic ulcer disease.
- Gallstones, cholecystitis.
- Acute pancreatitis.
- Chest wall pain, eg Tietze's syndrome, trauma, shingles, rib secondaries, osteoporosis.
- Aortic dissection.
- Anxiety, depression.
Depending on the clinical state of the patient and any suspicion of myocardial infarction, the patient may require immediate transfer to hospital before any investigations are performed.
- Investigations may be required to exclude non-cardiac causes of chest pain, eg chest X-ray (pneumonia), abdominal ultrasound (gallstones), serum amylase (acute pancreatitis).
- Initial blood investigations include cardiac enzymes, fasting lipids, fasting glucose and full blood count (to exclude anaemia, and high white cell count may suggest pneumonia).
- Resting ECG - a resting ECG is normal in over 90% of patients with recent symptoms of angina.
- Chest x-ray - this may be useful in evaluating the presence of heart failure or an alternative diagnosis, eg aortic aneurysm, pneumonia, rib fractures, rib secondaries or osteoporosis.
- Exercise ECG testing should not be used to diagnose or exclude stable angina for people without known coronary artery disease. See separate article on angina pectoris for further discussion on diagnosis of angina.
- Depending on the presentation, further investigations may include echocardiogram, coronary angiography, V/Q scan or pulmonary angiography (pulmonary embolus), CT aortography (aortic dissection) or upper gastrointestinal endoscopy (gastro-oesophageal reflux disease, peptic ulcer).
Referral to chest pain clinics
- For those patients not requiring immediate hospital admission, chest pain clinics enable rapid confirmation of the diagnosis, initiation of treatment, and, where considered appropriate, further investigation and intervention.
- Use of such services should be encouraged, although there is no randomised controlled trial to show that prompt assessment and management actually reduces cardiac morbidity and mortality.
- Patients should understand that further assessment may lead to a recommendation for more invasive treatment.
Further reading & references
- O'Regan DP, Harden SP, Cook SA; Investigating stable chest pain of suspected cardiac origin. BMJ. 2013 Jul 22;347:f3940. doi: 10.1136/bmj.f3940.
- Wood D, Timmis A, Halinen M; Rapid assessment of chest pain. BMJ. 2001 Sep 15;323(7313):586-7.
- Sekhri N, Feder GS, Junghans C, et al; How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart. 2007 Apr;93(4):458-63. Epub 2006 Jun 21.
- Ting HH, Lee TH, Soukup JR, et al; Impact of physician experience on triage of emergency room patients with acute chest pain at three teaching hospitals. Am J Med. 1991 Oct;91(4):401-8.
- Hani MA, Keller H, Vandenesch J, et al; Different from what the textbooks say: how GPs diagnose coronary heart disease. Fam Pract. 2007 Dec;24(6):622-7. Epub 2007 Oct 29.
- Chest pain of recent onset, NICE Clinical Guideline (March 2010)
- Angina - stable, Clinical Knowledge Summaries (September 2009)
- Capewell S, McMurray J; "Chest pain-please admit": is there an alternative?. A rapid cardiological assessment service may prevent unnecessary admissions. BMJ. 2000 Apr 8;320(7240):951-2.
- Norell M, Lythall D, Coghlan G, et al; Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic. Br Heart J. 1992 Jan;67(1):53-6.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Dr Colin Tidy