Chest pain CKS

Determine likelihood chest pain is angina

Typical angina (all 3 features), atypical angina (2/3 features) or non-anginal chest pain (≤1/3 feature)

Likelihood chest pain is angina

1.       Constricting discomfort in the front of the chest or in the neck, shoulders, jaw or arms

2.       Precipitated by physical exertion

3.       Relieved by rest or glyceryl trinitrate (GTN) within about five minutes

Likelihood chest pain is non-angina

1.       Persistent, localized chest pain [Pulmonary or MSK]

2.       Unrelated to physical exertion

3.       Pleuritic pain [Pulmonary or MSK]

4.       Chest pain associated with dizziness, palpitations, tingling, difficulty swallowing

Other history

• Cardiac-focus history:
  Sudden tearing chest pain radiating to the back and inter-scapular region [thoracic aneurysm]
  Sharp, constant sternal pain relieved by sitting forward [percarditis, cardiac tamponade]
  Ankle swelling, tiredness, severe breathlessness, orthopnea, frothy cough [acute heart failure].
  Associated palpitations, breathlessness, and syncope [arrhythmia]

• If chest pain with dyspnoea, explore further: acute-onset breathlessness, pleuritic chest pain, cough (dry or productive), wheeze, haemoptysis, fever, night sweats, weight loss

• Rule out lung cancer: chest/shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough

• Risk factors for IHD: established CAD, PAD, hypertension, diabetes, hyperlipidaemia, smoking, FH, obesity

• Other PMHx: reflux/GORD, gallstones, spinal disorders (cervical spondylosis)

• Social History: smoking, alcohol, occupation

• Explore PSO and whether recent stress or work pressure or anxiety are present

Examination

• Temperature [infection, pericarditis, or pancreatitis]

• Heart sounds (for murmurs and pericardial rub)

• BP both arms [aortic dissection]

• Heart rate [arrhythmias]

• Jugular venous pressure

• Lung fields, RR and O2 saturation [infection/pulmonary oedema/pleural effusion/PE]

• Chest wall examination [Costochondritis/Tietze’s syndrome, Bornholm’s disorder, Precordial catch-Texidor twinge]

• Signs of lung cancer [finger clubbing, cervical or supraclavicular lymphadenopathy]

• Abdomen [AAA, gallstones, pancreatitis, or peptic ulceration]

• Legs [DVT, heart failure, peripheral pulses PAD]

• Skin [shingles, rib fracture]

Investigation

1. Resting ECG: ST changes or Q waves, LBBB, ventricular hypertrophy, arrhythmia

2. Bloods: FBC, UE, LFTs, glucose, HBA1c, lipids, TFTs, Amylase, CRP ESR, NT-proBNP

3. CXR

A normal ECG does not rule out stable angina or ACS

Management

Chest pain requiring same-day assessment

• Current chest pain or chest pain <72hr

• Suspected ACS/unstable angina: chest pain >15 minutes, nausea & vomiting, sweating or breathlessness

• Systemically unwell (RR>30, HR>130bpm, SBP<90mmHg, O2 sats<92%, altered consciousness, pyrexial)

• Complications after suspected ACS (such as pulmonary oedema)

• Further chest pain after recent ACS (CAD, pericarditis, Dressler’s syndrome, PE)

Chest pain suitable for referral to hospital

• Chest pain >72hr ago and no complications

• Chest pain classified as typical angina (3/3 features), atypical angina (2/3 features)

• Chest pain classified as non-anginal chest pain (≤1/3 feature), however, abnormal resting ECG and/or CAD risk factors (age, smoking, diabetes, lipids, hypertension, family history)

• Suspected malignancy (such as lung cancer)

• Chest pain where the cause is unclear

Management options

Typical angina (3/3 features), atypical angina (2/3 features)
Refer to rapid access chest clinic (RAC)
Resting ECG
CT coronary angiography (≥64 slices) as their initial test

Non-anginal chest pain (≤1/3 feature)
Resting ECG (if ischaemia then needs CT coronary angiography
Assess the likelihood of IHD using risk factors and resting ECG and consider RAC referral

If no significant CHD is found (i.e. recent normal coronary angiogram). consider and investigate for other causes of the symptoms:

• Cardiac non-IHD: valve disease or hypertrophic cardiomyopathy [Cardiac Echo]

• Pulmonary disease, particularly lung malignancy [CXR]

• Musculoskeletal pain (Bornholm’s disease)

• Gastro-oesophageal reflux [GORD]

• Anxiety and depression

Hospital investigations (after resting ECG)

1. Non-invasive static imaging: CT coronary angiography

2. Non-invasive functional imaging: stress echo, exercise ECG, perfusion scintigraphy or MRI

3. Invasive: coronary angiography

Causes of chest pain

Cardiac
ACS (unstable angina, MI)
Stable angina
Dissecting thoracic aneurysm
Pericarditis
Cardiac tamponade
Myocarditis
Acute heart failure
Arrhythmias

Respiratory
Pulmonary embolus
Pneumothorax
Tension pneumothorax
Pneumonia
Asthma
Pleural effusion
Lung cancer

GIT
Acute pancreatitis
Oesophageal rupture
Peptic ulcer disease
GORD/oesophagitis
Oesophageal spasm
Acute cholecystitis

Other

• Musculoskeletal
  Costochondritis/Tietze’s syndrome - exercise/URTI trigger then weeks-to-months of sharp anterior chest wall pain and localised tenderness
  Bornholm’s disorder - unilateral, knife-like chest or upper abdominal pain, following an upper respiratory tract infection
  Precordial catch (Texidor twinge) - brief, episodic left-sided chest pain commonly associated with bending or posture, relieved by a single deep depth or straight posture; no radiation

• Herpes zoster

• Psychogenic