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
Stable Chest Pain
- 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
Investigation
- 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
Stable chest pain
- 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
Management
- ACS management should not delay transfer to hospital
- Pain relief: GTN (buccal or sublingual) and IV Morphine
- Aspirin 300 mg, unless contra-indicated (written record that been given)
- Oxygen: only offer if sats < 94 %, COPD 88-92%
- Monitor: Pain, HR, Rhythm, BP, O2 sats, ECG
NICE Source: CG95 Chest pain of recent onset: assessment and diagnosis. Summary compiled by Dr D P Sheppard MBBS.