WHEN TO USE THIS GUIDELINE

Use this guideline when chest pain suspected to be cardiac in origin

After an initial clinical assessment fails to identify a more likely explanation for chest pain other than angina or acute myocardial infarction
Do not use indiscriminately in all patients presenting with chest pain

Specific features of cardiac chest pain

Site: central, retrosternal
Character: pressure, heaviness, squeezing, burning (indigestion like)
Radiation: arm(s), neck, jaw, gums
Provoking factors: exercise, stress, cold temperature, lying down
Relieving factors: rest, GTN
Associated symptoms: nausea, sweating, breathlessness
Duration: > 15 min

CLINICAL ASSESSMENT

Perform 12-lead ECG on arrival. Repeat if further episodes of pain occur
Advice in algorithm

Initial management of emergency presentation with suspected cardiac chest pain

Next Question Here

When troponin result available

Recalculate HEART score

Score > 3

Discuss with senior colleague and refer for cardiac assessment. See Unstable Angina and Acute myocardial infarction

Score ≤3

Likely non-cardiac diagnosis
Discuss with senior colleague
Consider discharge

TREATMENT

Aspirin 300 mg oral (chew and swallow)
Glyceryl trinitrate 400 microgram/metered dose spray, 1–2 doses under tongue then close mouth
Diamorphine – see Acute myocardial infarction guideline

DISCHARGE FROM EMERGENCY PORTAL

Ensure patient is pain free
Repeat ECG before discharge
Request senior doctor review
Complete discharge summary – inform GP of ECG and troponin I results
Give patient an information sheet

Select one of each domain

History

Level of suspicion of cardiac chest pain (see specific features)

Select one:

Highly suspicious: specific features dominate +2 Moderately suspicious: mixture of specific and atypical features +1 Non-specific: no specific features +0

ECG

Select one:

Significant ST depression (in the absence of bundle branch block, left ventricular hypertrophy or digoxin therapy) +2 Any other abnormality +1 Normal +0

Age

Select one:

>65 yr +2 45 - 65 yr +1 <45 yr +0

Risk factors

(see Risk factors)

Select one:

≥3 risk factors or known atherosclerosis +2 1 or 2 risk factors +1 0 risk factors +0

HS Troponin I

Select one:

>80 ng/L +2 40 - 80 ng/L +1 <40 ng/L (Assume troponin is negative until result available) +0

Specific features of cardiac chest pain

Site: central, retrosternal
Character: pressure, heaviness, squeezing, burning (indigestion like)
Radiation: arm(s), neck, jaw, gums
Provoking factors: exercise, stress, cold temperature, lying down
Relieving factors: rest, GTN
Associated symptoms: nausea, sweating, breathlessness
Duration: > 15 min

Risk factors

The number of risk factors for coronary artery disease that are present determines the score for this domain for HEART score. The risk factors considered are:

diabetes mellitus
smoking – current or recent (<90 days)
hypercholesterolaemia
family history of coronary artery disease
obesity

As well as checking for the above risk factors, check for known Atherosclerosis

coronary revascularisation
myocardial infarction
stroke
peripheral arterial disease

ASSESSMENT OF CHEST PAIN

WHEN TO USE THIS GUIDELINE

Specific features of cardiac chest pain

CLINICAL ASSESSMENT

Initial management of emergency presentation with suspected cardiac chest pain

When troponin result available

TREATMENT

DISCHARGE FROM EMERGENCY PORTAL