Angina

Pericarditis

The table below gives characteristic exam question features for conditions causing chest pain

Risk factors for cardiovascular disease | | Pneumothorax | History of asthma, Marfan's etc Sudden dyspnoea and pleuritic chest pain | | Pulmonary embolism | Sudden dyspnoea and pleuritic chest pain Calf pain/swelling Current combined pill user, malignancy | | Pericarditis | Sharp pain relieved by sitting forwards May be pleuritic in nature | | Dissecting aortic aneurysm | 'Tearing' chest pain radiating through to the back Unequal upper limb blood pressure | | Gastro-oesophageal reflux disease | Burning retrosternal pain Other possible symptoms include regurgitation and dysphagia | | Musculoskeletal chest pain | One of the most common diagnoses made in the Emergency Department. The pain is often worse on movement or palpation. May be precipitated by trauma or coughing | | Shingles | Pain often precedes the rash |

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.