Chest Pain Recent Onset – NICE Guidance on a Page

Diagnosis

Refer to hospital for ACS protocol if 12 lead ECG abnormal OR chest pain per following:
- Pain in chest (arms, jaw, back) > 15 mins
- Associated symptoms: seating, N+V, SOB
- Abrupt deterioration in previously stable angina with little or no exertion
Refer to hospital for ACS protocol if signs of complications e.g. pulmonary oedema but pain free
Refer to hospital for ACS protocol if recent ACS and develop further chest pain
If pain free but had pain previous 12 hrs and normal ECG, or pain 12-72 hrs ago, then refer for urgent same day assessment
Cardiovascular Hx and risk factors: Age, Hypertension, Dyslipidaemia, Diabetes, Smoking, Family Hx
Universal definition: Cardiac biomarker (Troponin) > 99th centile upper reference limit, together with 1 of the following:
- Symptoms of ischaemia
- ST-T changes or LBBB
- Pathological Q waves
- Imaging loss of viable myocardium
Type 1: primary coronary event
Type 2: secondary to increased oxygen demand or reduced oxygen supply

Diagnose stable angina on clinical assessment. Typical angina if all 3, 2 = atypical, 1 = not angina:
- Constricting discomfort in front of chest, neck shoulder jaw
- Precipitated by exertion
- Relived by rest or GTN
Assess Coronary Artery Disease (CAD) risk: age, sex, DM, smoking, hyperlipidaemia
- If > 90 %: treat as it were angina
- 60-90 % perform coronary angiography
- 30-60 % functional imaging
- 10-20 % CT Calcium scoring
Identify non coronary causes of angina such as aortic stenosis

Resting 12 lead ECG as soon as possible
Take blood sample for Troponin I or T, repeat in 10-12 hrs (expected to rise 6 hrs post event)
If raised Troponin, reassess to exclude other causes i.e. secondary to PE, dissection
If ST segment elevation or new onset LBBB refer to local protocol for STEMI until firm diagnosis
If ST segment depression or deep T wave inversion refer to NSTEMI-Unstable angina protocol
If no ST changes but Q wave or T wave change consider refer to NSTEMI-Unstable angina protocol
DO not exclude ACS when ECG normal, consider serial ECGs or additional ECG leads
If NOT ACS need to exclude other life threatening conditions e.g. PE, aortic dissection, pneumonia

Full blood count to exclude anaemia
For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone, and is clinically appropriate then offer invasive coronary angiography, otherwise non-invasive functional imaging