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Chest pain: assessment of patients with suspected cardiac chest pain

Chest pain: assessment of patients with suspected cardiac chest pain

NICE updated it's guidelines in 2016 on the 'Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin'.

Below is a brief summary of the key points. Please see the link for more details.

Patients presenting with acute chest pain

Immediate management of suspected acute coronary syndrome (ACS)
  • glyceryl trinitrate
  • aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
  • do not routinely give oxygen, only give if sats < 94%*
  • perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS

Referral
  • current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
  • chest pain 12-72 hours ago: refer to hospital the same-day for assessment
  • chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

*NICE suggest the following in terms of oxygen therapy:
  • do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
  • people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
  • people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

Patients presenting with stable chest pain

NICE define anginal pain as the following:
  • 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 GTN in about 5 minutes
  • patients with all 3 features have typical angina
  • patients with 2 of the above features have atypical angina
  • patients with 1 or none of the above features have non-anginal chest pain

For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes):
  • 1st line: CT coronary angiography
  • 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
  • 3rd line: invasive coronary angiography

Examples of non-invasive functional imaging:
  • myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or
  • stress echocardiography or
  • first-pass contrast-enhanced magnetic resonance (MR) perfusion or
  • MR imaging for stress-induced wall motion abnormalities
+PassMedicine Notes

NICE updated it's guidelines in 2016 on the 'Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin'.

Below is a brief summary of the key points. Please see the link for more details.

Patients presenting with acute chest pain

Immediate management of suspected acute coronary syndrome (ACS)
  • glyceryl trinitrate
  • aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
  • do not routinely give oxygen, only give if sats < 94%*
  • perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS
Referral
  • current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
  • chest pain 12-72 hours ago: refer to hospital the same-day for assessment
  • chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action
*NICE suggest the following in terms of oxygen therapy:
  • do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
  • people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94-98%
  • people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88-92% until blood gas analysis is available.

Patients presenting with stable chest pain

NICE define anginal pain as the following:
  • 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 GTN in about 5 minutes
  • patients with all 3 features have typical angina
  • patients with 2 of the above features have atypical angina
  • patients with 1 or none of the above features have non-anginal chest pain
For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes):
  • 1st line: CT coronary angiography
  • 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
  • 3rd line: invasive coronary angiography
Examples of non-invasive functional imaging:
  • myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or
  • stress echocardiography or
  • first-pass contrast-enhanced magnetic resonance (MR) perfusion or
  • MR imaging for stress-induced wall motion abnormalities


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