Cardiac Type Chest Pain Presenting in Primary Care

It is often difficult to be certain as to whether chest pain is of cardiac or non-cardiac cause.¹ Any doubt should lead to referral to secondary care for further assessment, either to the local chest pain clinic or urgent hospital admission.

• 20-40% of all medical admissions are for acute chest pain.²
• CHD remains the principal cause of death in the UK and a fifth of these deaths occur 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 tight and crushing in quality. Aortic dissection tend to cause pain with a tearing quality; pericarditis and pulmonary pain tends to be worse on inspiration (pleuritic) and oesophageal reflux pain has a burning quality.
• Cardiac ischaemia pain tends to be retrosternal and may radiate to the jaw and/or the left arm.
• Angina is likely if chest discomfort or breathlessness are associated with effort, emotion, food or cold weather, symptoms are relieved by rest and/or GTN and one or more risk factors for coronary artery disease are present.³
• Predicting a stable clinical course from symptoms alone is also very difficult but very important as exertional angina can progress to unstable angina, acute myocardial infarction or even death.
• The assessment of any patient with possible cardiac chest pain should include smoking history, past history of cardiovascular disease and co-morbidities, 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, e.g. aortic stenosis can present with angina) and chest (to exclude signs of heart failure).
• Consider findings suggesting non-cardiac chest pain, e.g. tenderness of chest wall, epigastric tenderness due to peptic ulcer, focal lung signs associated with pneumonia.

The main causes of chest pain include:

• Angina, acute coronary syndrome (including myocardial infarction)
• Acute pericarditis
• Pneumonia, pulmonary embolus, pneumothorax
• Gastro-oesophageal reflux, oesophageal spasm
• Peptic ulcer disease
• Gallstones, cholecystitis
• Acute pancreatitis
• Chest wall pain, e.g. Tietze's syndrome, trauma, shingles, rib secondaries, osteoporosis
• Aortic dissection
• Anxiety, depression

Depending on 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, e.g. chest x-ray (pneumonia), abdominal ultrasound (gall stones), 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.⁴
• Chest x-ray; may be useful in evaluating presence of heart failure or alternative diagnosis, e.g. aortic aneurysm, pneumonia, rib fractures, rib secondaries or osteoporosis.
• 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).
• Exercise tolerance test (also known as exercise testing or exercise stress testing); is used routinely in evaluating patients who present with chest pain, in patients who have chest pain on exertion, and in patients with known ischaemic heart disease.⁵

According to the National Service Framework for coronary heart disease, all patients with symptoms of angina or suspected angina should receive "appropriate investigation":⁶

• There are a growing number of direct access 'chest pain' clinics in the country, with the majority run by secondary care.
• This enables 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.²
• Patients should understand that further assessment may lead to a recommendation for more invasive treatment.