1 Apr 2011

Chest Pain - NHS Clinical Knowledge Summary

Chest pain


In the right clinical topic?

Age from 18 years onwards
This CKS topic covers the management of adults presenting with chest pain in primary care. It includes recommendations on who should be admitted as an emergency, interim treatment if emergency admission is required, and investigations to determine the underlying cause if admission is not required.
This CKS topic does not cover the long-term management of the underlying causes of chest pain.
There are separate CKS topics on Angina, Asthma, Chest infections - adult, Chronic obstructive pulmonary disease, Heart failure - chronic, and Palpitations.
The target audience for this CKS topic is healthcare professionals working within the NHS in England, and providing first contact or primary healthcare.




Knowledge update

New evidence

Evidence-based guidelines
No new evidence-based guidelines since 1 February 2011.
HTAs (Health Technology Assessments)
No new HTAs since 1 February 2011.
Economic appraisals
No new economic appraisals relevant to England since 1 February 2011.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 February 2011.
Primary evidence
No new randomized controlled trials published in the major journals since 1 February 2011.

New policies

No new national policies or guidelines since 1 February 2011.

New safety alerts

No new safety alerts since 1 February 2011.

Changes in product availability

No changes in product availability since 1 February 2011.

Goals and outcome measures

Goals

To support primary healthcare professionals:
  • To decide whether emergency admission is required
  • To determine the underlying cause of the chest pain
  • To appropriately refer the person for further investigation and treatment

Background information

What is it?

  • Chest pain refers to pain in the thorax [LeBlond et al, 2008].
  • Chest pain can be classified by [Murtagh, 2007; Schroeder, 2008]:
    • Cause (such as cardiac versus non-cardiac).
    • Type (such as localized versus poorly localized, or pleuritic versus non-pleuritic).

What causes it?

Potentially life-threatening causes

  • Potentially life-threatening causes of chest pain include:
    • Cardiac causes
      • Acute coronary syndrome (unstable angina and myocardial infarction).
      • Dissecting thoracic aneurysm.
      • Pericarditis, cardiac tamponade, or myocarditis.
      • Acute congestive cardiac failure.
      • Arrhythmias.
    • Respiratory causes
      • Pulmonary embolus.
      • Pneumothorax or tension pneumothorax.
      • Community-acquired pneumonia.
      • Asthma.
      • Pleural effusion.
    • Gastroenterological causes
      • Acute pancreatitis.
      • Oesophageal rupture.
    • Cancer (for example, lung cancer).
  • For information on the clinical features of life-threatening causes of chest pain, see Potentially life-threatening causes.

Non-life-threatening causes

  • Non-life-threatening causes of chest pain include:
    • Cardiac causes
      • Stable angina.
    • Musculoskeletal causes
      • Rib fracture.
      • Costochondritis.
      • Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction).
      • Osteoarthritis or rheumatoid arthritis.
      • Osteoporosis.
      • Fibromyalgia.
      • Polymyalgia rheumatica.
    • Gastroenterological causes
      • Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis.
    • Other causes
      • Psychogenic or non-specific chest pain.
      • Herpes zoster.
      • Bornholm's disorder (Coxsackie B virus infection).
      • Precordial catch (Texidor twinge).
  • For information on the non-life-threatening causes of chest pain, see Non-life threatening causes.

How common is it?

  • Chest pain accounts for about 1–2% of all consultations in primary care, 5% of visits to Accident and Emergency departments, and 40% of emergency hospital admissions [Ruigomez et al, 2009].
  • The prevalence of chest pain among all people attending primary care was 0.7% in a German prospective study investigating 1212 people presenting to primary care with chest pain. The majority of people were women (55.9%) [Bösner et al, 2009].
  • Chest pain was a presenting symptom in 2.7% of all consultations in over 24,000 people presenting to primary care in Switzerland, as reported in a systematic review [Verdon et al, 2008].

Management

Which scenario?

  • Scenario: Assessment and diagnosis: covers the clinical features of the common causes of life-threatening and non-life-threatening chest pain, how to identify the cause of chest pain in primary care, and how to make a diagnosis of stable angina and acute coronary syndrome.
  • Scenario: Management: covers the management of chest pain in primary care. This includes the management of people requiring emergency admission, and the investigation, management, and referral of people who do not require emergency admission.

Scenario: Assessment and diagnosis

How should I assess a person with chest pain?

What history should I take from a person with chest pain?
  • If the person is unwell with chest pain, admit them immediately to hospital for treatment.
  • Ask about:
    • The nature, onset, duration, site, and radiation of chest pain. An acute onset, with central or band-like chest pain which radiates to the person's jaw, arms, or back, is strongly suggestive of cardiac chest pain (see Suspecting acute coronary syndrome). Persistent, localized chest pain is more suggestive of a respiratory or musculoskeletal cause.
    • Exacerbating and relieving factors of chest pain. Chest pain related to exertion is typical of angina (see Suspecting stable angina). Chest pain that is related to inspiration (pleuritic) may suggest a musculoskeletal or respiratory cause.
    • Associated symptoms. Breathlessness can be seen with cardiac or respiratory causes of chest pain. Chest pain associated with palpitations, dizziness, or difficulty swallowing is less likely to be angina.
    • A history of chest pain and previous investigations (for example electrocardiogram or chest X-ray). A recent normal coronary angiogram is helpful to exclude coronary artery disease as a cause of chest pain.
    • A history of stable angina or myocardial infarction, and assess for cardiovascular risk factors (such as older age, male gender, smoking, hypertension, diabetes mellitus, increased cholesterol and other lipid levels, and a family history of cardiovascular disease). Risk factors increase the likelihood of significant coronary artery disease (see Non-anginal chest pain).
    • A history of respiratory and gastroenterological disease, musculoskeletal problems, and previous trauma. Musculoskeletal and gastrointestinal disorders are a common cause of chest pain in primary care and are often overlooked.
    • A history of anxiety and depression. Psychogenic or non-specific chest pain is a common cause of chest pain in primary care and should be considered if there are clinical features suggesting the diagnosis (see the CKS topic on Depression).
Basis for recommendation
These recommendations are based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008] produced by the Royal College of General Practitioners, an American review article Diagnosing the cause of Chest Pain [Cayley, 2005], an Australian primary care clinical textbook [Murtagh, 2007], and the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
Admit people who are unwell with chest pain
History of chest pain and investigations
  • The description of chest pain is the most important clinical factor in distinguishing life-threatening causes of chest pain from non-life-threatening causes [Murtagh, 2007].
Clinical features of chest pain and examination
  • In primary care, the key to the appropriate management of chest pain is a carefully conducted history and focused examination. Knowledge of the main features of different causes of chest pain is important, and rarer causes should always be considered [Schroeder, 2008].
History of angina, myocardial infarction, and cardiovascular risk factors
  • The Scottish Intercollegiate Guideline Network (SIGN) recommends that the nature of the chest pain, a prior history of angina, the person's age and sex, and their cardiovascular risk factors should all be determined when assessing the likelihood of cardiac chest pain [SIGN, 2007a].
  • Cardiovascular risk factors are based on expert consensus in guidelines from the UK [British Cardiac Society et al, 2005; SIGN, 2007b] and Europe [Fox et al, 2006], and a NICE guideline [NICE, 2010].
  • Up to 3% of people initially diagnosed with non-cardiac chest pain suffer death or myocardial infarction within 30 days of presentation. People with cardiac risk factors are at a higher risk of cardiac chest pain so require closer follow up [Miller et al, 2004].
What examination should I do for a person with chest pain?
  • If the person is unwell with chest pain, admit them immediately to hospital for treatment.
  • Check:
    • General appearance for pallor and sweating (shock).
    • Heart sounds (for murmurs and pericardial rub), blood pressure in both arms (possible aortic dissection), pulse rate and rhythm (shock and arrhythmias), and jugular venous pressure and ankles (for oedema, indicating heart failure).
    • Chest wall for tenderness, and assess whether movement of the chest wall reproduces the pain (indicating musculoskeletal chest pain). Listen to the person's lung fields (infection). Measure the respiratory rate and carry out pulse oximetry (low oxygen saturation).
    • Abdomen for tenderness (gallstones, pancreatitis, or peptic ulceration).
    • Neck for localized tenderness and stiffness (cervical spondylosis or osteoarthritis).
    • Legs for swelling or tenderness (deep vein thrombosis).
    • Skin for rashes (shingles) and bruising (rib fracture).
    • Temperature (infection, pericarditis, or pancreatitis).
Basis for recommendation
These recommendations are based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008] produced by the Royal College of General Practitioners, an American review article Diagnosing the cause of Chest Pain [Cayley, 2005], an Australian primary care clinical textbook [Murtagh, 2007], and the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
Admit people who are unwell with chest pain
Clinical features of chest pain and examination
  • In primary care, the key to appropriate management of chest pain is a carefully conducted history and focused examination. Knowledge of the main features of different causes of chest pain is important, and rarer causes should always be considered [Schroeder, 2008].
What investigations should I do for people with chest pain in primary care
  • If the person with chest pain requires admission or referral to hospital do not delay management to arrange investigations in primary care.
  • If the person does not require immediate admission or referral, consider the following investigations depending on the suspected cause of chest pain:
    • Electrocardiography (ECG) — to look for signs of ventricular hypertrophy, arrhythmia, pulmonary embolism, stable angina, and acute coronary syndrome (ACS). See the CKS topics on Pulmonary embolism and Palpitations.
      • An ECG does not give a definitive diagnosis of angina but provides information on heart rhythm (for example to check for arrhythmias [such as atrial fibrillation] or conduction defects [such as heart block and bundle-branch block]) and identifies signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction (see Diagnosing acute coronary syndrome and Diagnosing stable angina).
    • Blood glucose, lipid profiles, and urea and electrolyte levels — to review the person's cardiovascular risk profile. See the CKS topic on CVD risk assessment and management.
    • Full blood count — to check for anaemia exacerbating stable angina.
    • Thyroid function tests — to check for thyroid disease. See the CKS topics on Hyperthyroidism and Hypothyroidism.
    • Liver function tests and amylase — to check for cholecystitis and pancreatitis. See the CKS topics on Chronic pancreatitis and Acute cholecystitis.
    • C-reactive protein or erythrocyte sedimentation rate (ESR) — for evidence of infection or inflammation. See the CKS topics on Chest infection - adults, Polymyalgia rheumatica, and Osteoarthritis.
    • Chest X-ray — to look for signs of heart failure and pulmonary pathology (including pleural effusion, lobar collapse, lung cancer). See the CKS topics on Heart failure - chronic and Lung cancer - suspected.
  • Further investigations depend on the underlying cause of chest pain.
Basis for recommendation
Blood tests
  • These recommendations are based on: the National Service Framework for Coronary Heart Disease [DH, 2000]; expert consensus in guidelines from the UK [SIGN, 2007b] and Europe [Fox et al, 2006]; expert opinion in review articles [Thadani, 2006; Khan and Dutka, 2008]; and the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
  • Some blood tests (such as haemoglobin and thyroid hormone levels) help to identify a possible cause contributing to the ischaemia, whereas others (such as glucose, lipid profiles, and urea and electrolyte levels) aid assessment of the person's risk profile [Fox et al, 2006; Schroeder, 2008].
Electrocardiography (ECG)
  • This recommendation is based on: the National Service Framework for Coronary Heart Disease [DH, 2000]; expert consensus in guidelines from the UK [SIGN, 2007b], Europe [Fox et al, 2006], and the US [ACC and AHA, 2002]; and expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by NICE [NICE, 2010].
  • A resting ECG does not give a definitive diagnosis of angina but provides information on heart rhythm (for example to check for arrhythmias [such as atrial fibrillation] or conduction defects [such as heart block and bundle-branch block]) and identifies signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction [ACC and AHA, 2002; Fox et al, 2006; SIGN, 2007b]. This information can help selection of further investigations or treatment, and aid risk assessment [Fox et al, 2006].
  • A normal ECG does not exclude angina [Fox et al, 2006; SIGN, 2007b; NICE, 2010] — more than 50% of people with stable angina have a normal resting ECG [Snow et al, 2004].
Chest X-ray
  • The recommendation not to routinely request chest radiography for people with angina is based on expert consensus guidelines from Europe [Fox et al, 2006] and the US [ACC and AHA, 2002], on expert opinion [Snow et al, 2004], and on the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by NICE [NICE, 2010].
  • Chest radiography is not recommended because it is not specific for either diagnosis or risk assessment for angina unless the person has suspected heart failure or valve, pericardial, or pulmonary disease [ACC and AHA, 2002; Snow et al, 2004; Fox et al, 2006; NICE, 2010].
Further investigations depend on the underlying cause of chest pain
  • This recommendation is based on expert opinion from a review article Assessment of chest pain in primary care produced by the Royal College of General Practitioners [Schroeder, 2008].

What are the potentially life-threatening causes of chest pain?

What are the life-threatening cardiovascular causes of chest pain?
  • Cardiovascular causes include:
    • Acute coronary syndrome (unstable angina and myocardial infarction).
    • Dissecting thoracic aneurysm
      • Symptoms — sudden tearing chest pain radiating to the back and inter-scapular region.
      • Signs — high blood pressure, blood pressure differentials (different in both arms), inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic value regurgitation); and occasionally a pericardial friction rub. Neurological deficits may be present (such as hemiplegia).
    • Pericarditis/cardiac tamponade
      • Symptoms — sharp, constant sternal pain relieved by sitting forward. Pain may radiate to the left shoulder and left arm, and is worse when lying on the left side and on inspiration, swallowing, and coughing. Other symptoms may include fever, cough, and arthralgia. A cardiac tamponade may have associated breathlessness, dysphagia, cough, and hoarseness.
      • Signs — pericardial friction rub (high pitched scratching sound, best heard over the left sternal border during expiration). Signs of a cardiac tamponade include pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration); and hypotension, muffled heart sounds, and jugular venous distention (Beck's Triad).
    • Acute congestive cardiac failure
      • Symptoms — severe breathlessness, orthopnea, and coughing (rarely producing frothy, blood-stained sputum).
      • Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (often) wheeze. Peripheral circulation is shut down (in contrast to people with an acute exacerbation of chronic obstructive pulmonary disease).
      • To confirm a diagnosis of acute congestive cardiac failure, see the scenario Suspected heart failure in the CKS topic Heart failure - chronic.
    • Arrhythmias
      • Symptoms — chest pain associated with palpitations, breathlessness, and syncope (or near syncope).
      • Signs — bradycardia or tachycardia.
      • To confirm the diagnosis of an arrhythmia, see the CKS topic on Palpitations.
Basis for recommendation
Dissecting thoracic aneurysm
  • These recommendations are based on expert opinion in two review articles Identifying Chest Pain Emergencies in the Primary Care Setting [Winters and Katzen, 2006] and Assessment of chest pain in primary care [Schroeder, 2008]; the Oxford text book of Medicine [Dwight, 2010], and an Australian primary care clinical textbook [Murtagh, 2007].
Pericarditis/cardiac tamponade
  • These recommendations are based on expert opinion in two review articles Identifying Chest Pain Emergencies in the Primary Care Setting [Winters and Katzen, 2006] and Assessment of chest pain in primary care [Schroeder, 2008]; the Oxford text book of Medicine [Dwight, 2010], and an Australian primary care clinical textbook [Murtagh, 2007].
Acute congestive cardiac failure
Arrhythmias
  • This information is based on the Thames Valley Cardiac Network protocol for the management of palpitations in primary care, representing the consensus opinion of 16 experts [Arrhythmia & Sudden Cardiac Death Subgroup, 2007]; and is in line with the National service framework on arrhythmias and sudden cardiac death [DH, 2005].
What are the life-threatening respiratory causes of chest pain?
  • Respiratory causes include:
    • Pulmonary embolism
      • Symptoms — acute-onset breathlessness, pleuritic chest pain, cough, haemoptysis. Recurrent acute episodes may lead to chronic breathlessness.
      • Signs — tachypnoea of more than 20 breaths per minute, tachycardia, signs of deep vein thrombosis (DVT).
      • To confirm a diagnosis of pulmonary embolism, see the scenario When to suspect in the CKS topic Pulmonary embolism.
    • Pneumothorax or tension pneumothorax
      • Symptoms — sudden-onset pleuritic pain and breathlessness in people with or without existing lung disease.
      • Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in a rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
    • Community-acquired pneumonia
      • Symptoms — cough and at least one other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain.
      • Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance) plus at least one systemic feature (such as fever or sweating, myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.
      • To confirm the diagnosis of community-acquired pneumonia, see the scenario Diagnosis in the CKS topic on Chest infections - adult.
    • Asthma
      • Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
      • Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
      • To confirm a diagnosis of asthma, see the CKS topic on Asthma.
    • Lung or lobar collapse
      • Symptoms — localized chest pain, breathlessness, cough.
      • Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
    • Lung cancer
      • Symptoms — chest or shoulder pain, haemoptysis, dyspnoea, weight loss, hoarseness, and cough.
      • Signs — finger clubbing, cervical or supraclavicular lymphadenopathy
      • To confirm a diagnosis of lung cancer, see the CKS topic on Lung cancer - suspected.
    • Pleural effusion
      • Symptoms — localized chest pain and progressive breathlessness.
      • Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.
Basis for recommendation
Pulmonary embolism
  • These recommendations are based on evidence from a diagnostic study of the clinical features associated with confirmed pulmonary embolism [Stein et al, 1991].
Pneumothorax
  • These recommendations are based on expert observation reported in the Oxford textbook of medicine [Davies et al, 2010].
Tension pneumothorax
  • These recommendations are based on expert observation reported in the Oxford handbook of general practice [Simon et al, 2010].
Community-acquired pneumonia
Lung/lobar collapse
  • These recommendations are based on expert observation reported in the textbook Clinical medicine [Frew and Holgate, 2005].
Asthma
  • These recommendations are based on expert observation, supported by observational studies reported in the British guideline on the management of asthma, issued by the British Thoracic Society and the Scottish Intercollegiate Guidelines Network [SIGN and BTS, 2008].
Lung cancer
  • These recommendations are based on the guideline Referral guidelines for suspected cancer: lung cancer produced by the National Institute for Health and Clinical Excellence [NICE, 2005b].
Pleural effusion
  • These recommendations are based on expert observation reported in the Oxford textbook of medicine [Davies et al, 2010].
What are the life-threatening gastrointestinal causes of chest pain?
  • Gastrointestinal causes include:
    • Acute pancreatitis
      • History — the person may have a history of gallstones or excessive alcohol consumption.
      • Symptoms — sudden-onset pain that is typically severe, continuous, and boring in nature. Usually in the epigastric region, but it may be generalized. Pain may radiate to the right upper quadrant, chest, flanks, and lower abdomen; it is relieved by sitting upright and leaning forward, and is worse in the supine position. Typically pain increases in severity to a peak during the first few hours, before reaching a plateau that may last for several days. There is associated nausea and vomiting.
      • Signs — abdominal tenderness (mild tenderness in the upper abdomen to generalized peritonitis), abdominal distension, Cullen's sign (a bluish discolouration around the umbilicus), or Grey–Turner's sign (bluish discolouration around the flank), and low blood pressure. There is low grade fever.
      • To confirm a diagnosis of acute pancreatitis, see the scenario Diagnosis in the CKS topic on Pancreatitis - acute.
    • Oesophageal rupture
      • History — a recent history of a medical procedure, foreign body ingestion, or oesophageal cancer.
      • Symptoms — thoracic oesophageal perforation leads to chest pain, dyspnoea, and odynophagia.
      • Signs — classical findings include fever and subcutaneous emphysema (around the neck and upper chest wall).
Basis for recommendation
Acute pancreatitis
Oesophageal rupture
  • These recommendations are based on expert opinion in a review article Identifying Chest Pain Emergencies in the Primary Care Setting [Winters and Katzen, 2006].

What are the non-life-threatening causes of chest pain?

What are the non-life-threatening cardiac causes of chest pain?
Basis for recommendation
The clinical features of stable angina are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
What are the musculoskeletal causes of chest pain?
  • Musculoskeletal causes of chest pain include:
    • Rib fracture
      • History — previous history of trauma or coughing.
      • Symptoms — unilateral, sharp chest pain, worse with inspiration.
      • Signs — bruising and tenderness on palpation over the affected rib.
    • Costochondritis
      • Symptoms — unilateral, sharp, anterior chest-wall pain, exaggerated by breathing, activity, or a particular posture. Usually preceded by exercise or an upper respiratory tract infection, and can last for months.
      • Signs — tenderness over the costochondral junction and pain in the affected area when palpating the chest wall. In Tietze's syndrome, there is a tender, fusiform swelling of the costal cartilage at the costochrondral junction.
    • Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)
      • Symptoms — dull and aching chest pain aggravated by particular movements of the neck. Commonly, exercise makes the pain worse and rest relieves it, but the opposite may also be true. Pain radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae. May be associated with headache or dizziness, or pain in the spine.
      • Signs — may be associated with paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength.
      • To confirm a diagnosis of neck pain, see the scenario Diagnosis in the CKS topic Neck pain - non-specific.
Basis for recommendation
Musculoskeletal chest pain
  • The recommendation that chest wall tenderness is not a reliable sign to rule out cardiac chest pain is based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008] produced by the Royal College of General Practitioners.
Costochondritis and cervical spinal disorders
  • These recommendations are based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008], produced by the Royal College of General Practitioners and a primary care clinical textbook [Murtagh, 2007].
What are the non-life-threatening gastrointestinal causes of chest pain?
  • Gastrointestinal causes of chest pain include:
    • Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis
      • Symptoms — sub-sternal pain, which commonly occurs at night or after consumption of a large meal. Epigastric pain often radiates to the throat and is worse when bending or lying flat. Regurgitation of acid and food into the mouth can occur.
      • To confirm a diagnosis of peptic ulcer, gastro-oesophageal reflux, or oesophagitis, see the CKS topic on Dyspepsia - unidentified cause.
    • Acute cholecystitis
      • History — the person may have a history of gallstones (cholelithiasis). Cholecystitis without biliary colic usually has a gradual onset.
      • Symptoms — sudden-onset, constant, severe pain in the upper right quadrant; and possibly anorexia, nausea, vomiting, and sweating. Low grade fever (a high temperature is uncommon).
      • Signs — tenderness in the upper right quadrant, with or without Murphy's sign (inspiration is inhibited by pain on palpitation) on examination. There may also be fever (evidence of sepsis) and jaundice (stone in the bile duct or external compression of the biliary ducts).
      • To confirm a diagnosis of cholecystitis, see the scenario Diagnosis in the CKS topic on Cholecystitis - acute.
Basis for recommendation
Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis
  • These recommendations are based on the expert observation reported in the Oxford textbook of medicine [Neale, 2010], and the guideline Dyspepsia: management of dyspepsia in adults in primary care [NICE, 2005a], produced by the National Institute for Health and Clinical Excellence.
Acute cholecystitis
What are some other causes of non-life-threatening chest pain?
  • Others causes of chest pain include:
    • Psychogenic or non-specific chest pain
      • History — the person has no identifiable risk factors for a physical cause of chest pain. Anxiety disorders are common, especially panic disorders. The episode is often preceded by a stressful event.
      • Symptoms — chest pain is usually in the left sub-mammary position (without radiation). The pain is sharp and continuous. The pain is aggravated by tiredness and stress, and may be associated with symptoms of hyperventilation (including tingling of the extremities) and palpitations.
    • Herpes zoster
      • Symptoms — intense, often sharp, unilateral pain. Pain may be present for days before the shingles rash appears.
      • Signs — prodrome of fever and myalgia, with burning, tingling, numbness, or pruritus in the affected skin. Painful maculopapular rash lasting 7–10 days which develops into vesicular lesions in a dermatomal distribution (most commonly on the thorax). Lesions crust over at 2–4 weeks.
      • To confirm a diagnosis of herpes zoster, see the scenario Diagnosis in the CKS topic on Shingles.
    • Bornholm's disorder (Coxsackie B virus infection)
      • Symptoms — unilateral, knife-like chest or upper abdominal pain, following an upper respiratory tract infection.
      • Signs — normal examination.
    • Precordial catch (Texidor twinge)
      • Symptoms — brief, episodic left-sided chest pain commonly associated with bending or posture, relieved by a single deep depth or straight posture. No radiation.
      • Signs — normal examination.
Basis for recommendation
Psychological chest pain
  • These recommendations are based on a primary care clinical textbook [Murtagh, 2007].
Herpes zoster
Bornholm's disorder (Coxsackie B virus infection)
  • These recommendations are based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008], produced by the Royal College of General Practitioners, and a primary care clinical textbook [Murtagh, 2007].
Precordial catch (Texidor twinge)
  • These recommendations are based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008], produced by the Royal College of General Practitioners, and a primary care clinical textbook [Murtagh, 2007].

Acute coronary syndrome

When should I suspect acute coronary syndrome?
  • Suspect acute coronary syndrome, if:
    • Pain in the chest or other areas (for example the arms, back, or jaw) lasts longer than 15 minutes.
    • Chest pain is associated with nausea and vomiting, sweating or breathlessness, or a combination of these.
    • Chest pain is associated with haemodynamic instability (for example the person has a systolic blood pressure less than 90 mmHg).
    • Chest pain is of a new-onset, or is the result of an abrupt deterioration of stable angina; with pain occurring frequently with little or no exertion, and often lasting longer than 15 minutes.
  • Do not use the person's response to glyceryl trinitrate to confirm or exclude a diagnosis of acute coronary syndrome.
  • See Diagnosing acute coronary syndrome.
Basis for recommendation
These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
How should I diagnose acute coronary syndrome in primary care?
  • Most people require admission or referral to hospital to confirm the diagnosis of acute coronary syndrome (ACS).
  • People with clinical features of ACS require a resting 12-lead electrocardiogram and blood troponin level to confirm the diagnosis.
  • If the person's pain was more than 72 hours ago and they have no complications, consider diagnosing ACS in primary care. Arrange:
    • An electrocardiogram (ECG) — ECG changes that may indicate ischaemia or previous myocardial infarction include:
      • Pathological Q waves (in particular).
      • Left bundle branch block (LBBB).
      • ST-segment and T-wave abnormalities (for example T-wave flattening or elevation, or T-wave inversion).
      • A normal ECG does not confirm or exclude a diagnosis of ACS.
    • A blood test for serum troponin — cardiac troponin I and T are used to differentiate unstable angina from myocardial infarction.
      • A detectable troponin level indicates damage to the myocardium (for example myocardial infarction). The threshold depends on the laboratory.
      • Serum troponin is normally detectable within 12 hours following a myocardial infarction, and becomes undetectable 1–2 weeks afterwards.
      • Other conditions that directly or indirectly damage heart muscle (such as arrhythmias, pericarditis, pulmonary emboli, and myocarditis) can also cause an increase in serum troponin.
Basis for recommendation
This information is based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [Thygesen et al, 2007; NICE, 2010].
  • The information on serum troponin (cardiac troponin I and T) is based on expert opinion from a review article [Ammann et al, 2004].

Stable angina

When should I suspect stable angina?
  • Suspect stable angina, if :
    • There is constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms, and
    • Pain is precipitated by physical exertion, and
    • Pain is relieved by rest or glyceryl trinitrate within about 5 minutes.
  • Describe the pain as:
    • Typical angina if it has all three features.
    • Atypical angina if it only has two features.
    • Non-anginal chest pain if it has one or no features.
  • Stable angina is unlikely if any of the following apply:
    • Pain is continuous or very prolonged.
    • Pain is unrelated to activity.
    • Pain is brought on by breathing in.
    • Pain is associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing.
  • See Diagnosing stable angina.
Basis for recommendation
These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
How should I make a diagnosis of stable angina?
  • Diagnose stable angina on the basis of:
    • Typicality of pain, and
    • Age, sex, and cardiovascular risk factors (diabetes, smoking, and total cholesterol greater than 6.47 mmol/L).
  • If a diagnosis of stable angina cannot be made on clinical history, take a resting electrocardiogram (ECG) — an abnormal ECG makes the diagnosis of coronary artery disease more likely, but does not confirm that the chest pain is stable angina. ECG changes that may indicate ischaemia or previous myocardial infarction include:
      • Pathological Q waves (in particular).
      • Left bundle branch block (LBBB).
      • ST-segment and T-wave abnormalities (for example T-wave flattening or elevation, or T-wave inversion).
      • A normal ECG does not confirm or exclude a diagnosis of stable angina.
  • If the person has typical anginal pain and an estimated likelihood of coronary artery disease greater than 90%, diagnose stable angina. No further diagnostic tests are necessary. Treat as stable angina. See the CKS topic on Angina.
  • If the person has non-anginal chest pain and their assessment does not raise suspicion of stable angina, exclude stable angina and consider other causes of chest pain (such as musculoskeletal chest pain).
  • If the person has typical or atypical anginal pain and an estimated likelihood of coronary artery disease of 90% or less, refer them to a specialist chest pain service, to confirm or exclude the diagnosis of stable angina. See Management - not requiring admission.
Typical angina
  • Typical angina has all three features of constricting pain, that is induced by exercise, and is relieved by rest or glyceryl trinitrate within about 5 minutes.
  • For men older than 70 years of age with typical symptoms, assume an estimated risk of greater than 90%.
  • For women older than 70 years of age with typical symptoms and high risk factors, assume an estimated risk of greater than 90%.
Table 1. Percentage of people estimated to have coronary artery disease (CAD) with typical anginal pain.
Age
Men
Women
Low
High
Low
High
35
30
88
10
78
45
51
92
20
79
55
80
95
38
82
65
93
97
56
84
If there are resting electrocardiogram ST–T-wave changes or Q waves, the likelihood of CAD is higher in each cell of the table.
HIGH RISK = diabetes mellitus + smoking + hyperlipidaemia (total cholesterol greater than 6.47 mmol/L).
LOW RISK = none
Data from: the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
Atypical angina
  • Atypical angina is two out of the three features of constricting pain, that is induced by exercise, and is relieved by rest or glyceryl trinitrate within about 5 minutes.
  • For men older than 70 years of age with atypical symptoms, assume an estimated risk of greater than 90%.
  • For women older than 70 years of age, assume an estimated risk of 61–90%.
Table 1. Percentage of people estimated to have coronary artery disease (CAD) with atypical anginal pain.
Age
Men
Women
Low
High
Low
High
35
8
59
2
39
45
21
70
5
43
55
45
79
10
47
65
71
86
20
51
If there are resting electrocardiogram ST–T-wave changes or Q waves, the likelihood of CAD is higher in each cell of the table.
HIGH RISK = diabetes mellitus + smoking + hyperlipidaemia (total cholesterol greater than 6.47 mmol/L).
LOW RISK = none.
Data from: the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
Non-anginal chest pain
  • Non-anginal pain has one or none of the features of constricting pain, that is induced by exercise, and is relieved by rest or glyceryl trinitrate within about 5 minutes.
Table 1. Percentage of people estimated to have coronary artery disease (CAD) with non-anginal chest pain.
Age
Men
Women
Low
High
Low
High
35
3
35
1
19
45
9
47
2
22
55
23
59
4
25
65
49
69
9
29
If there are resting electrocardiogram ST–T-wave changes or Q waves, the likelihood of CAD is higher in each cell of the table.
HIGH RISK = diabetes mellitus + smoking + hyperlipidaemia (total cholesterol greater than 6.47 mmol/L).
LOW RISK = none.
Data from: the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
Basis for recommendation
These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].

Scenario: Management of chest pain

Admission

  • Most people with potentially life-threatening causes of chest pain require hospital admission and will need initial pre-hospital management prior to transfer.
  • See Who to admit (admission criteria) and Management while awaiting admission (while awaiting admission).
Which people with chest pain need hospital admission?
Basis for recommendation
CKS found no specific guidelines on when to admit people with chest pain to hospital. These recommendations are based on a number of guidelines produced by UK national organizations [Joint Royal Colleges Ambulance Liaison Committee, 2006; British Thoracic Society, 2008; NICE, 2010].
Clinical features of a life-threatening cause of chest pain
Blood pressure, pulse rate, respiratory rate, temperature, and level of consciousness
  • The modified early warning system (MEWS), recommended by the British Thoracic Society (BTS), assesses and classifies the seriousness of the condition of an acutely unwell person (on the basis of their blood pressure, pulse, temperature, breathing rate, and level of consciousness) to determine their need for urgent medical care [British Thoracic Society, 2008].
    • MEWS is based on evidence (from a prospective cohort study of 673 medical admissions) of the association between vital signs and the person's level of consciousness, and the risk of death, risk of cardiac arrest, and need for treatment in a high dependency or intensive care unit [Subbe et al, 2001].
  • CKS takes the view that the similarity of the recommended methods of assessing risk in widely differing conditions can be taken as evidence that these methods of assessment can reasonably be extrapolated to all people who are acutely ill, whatever the cause, and to people with chest pain where the cause is unknown.
Oxygen saturation less than 92%
  • The Scottish Intercollegiate Guidelines Network (SIGN) and BTS guideline on the management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
  • The BTS guidelines for the management of community acquired pneumonia in adults: update 2009 recommend that pulse oximetry should be available to general practitioners to assess severity and oxygen requirement in people with community-acquired pneumonia and other acute respiratory illnesses [British Thoracic Society, 2009].
Admit people with acute coronary syndrome
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
How should I manage people with chest pain requiring hospital admission?
  • Sit the person up.
  • Do not routinely administer oxygen. Only offer supplemental oxygen to people with:
    • Oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure.
      • Use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target SpO2 of 94–98%.
    • Chronic obstructive pulmonary disease, who are at risk of hypercapnic respiratory failure.
      • Use a 28% venturi mask. Keep the flow rate at 4 L/min to achieve a target SpO2 of 88–92%.
  • If the person has suspected:
    • Acute coronary syndrome
      • Treat pain with glyceryl trinitrate (GTN) and/or opiates (for example diamorphine 2.5 mg to 5.0 mg).
      • Give aspirin 300 mg (unless there is clear evidence that the person is allergic to it). Send a written record with the person that aspirin has been given.
      • Take a resting 12-lead electrocardiogram (ECG). Send the results to the hospital. Recording and sending the ECG should not delay transfer to hospital.
    • Acute pulmonary oedema
      • Give a nitrate, either sublingually or buccally (for example GTN spray, two puffs).
      • Give an intravenous diuretic and an anti-emetic (for example furosemide 40 mg to 80 mg and metoclopramide 10 mg).
    • Tension pneumothorax, if the person's condition is life threatening:
      • Consider inserting a large-bore cannula through the second intercostal space in the mid-clavicular line, on the side of the pneumothorax.
  • Monitor (use clinical judgement to decide how often this should be done):
    • Exacerbations of pain and other symptoms.
    • Pulse, blood pressure, and heart rhythm.
    • Oxygen saturation (by pulse oximetry).
    • Resting 12-lead ECG (repeat if necessary)
    • Pain relief (check if it is effective).
  • For information on managing people with other conditions (prior to hospital admission), see the CKS topics on Asthma, Chronic obstructive pulmonary disease, Palpitations, and Chest infection - adults.
Basis for recommendation
Oxygen therapy
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
  • The use of a venturi mask is based on expert opinion published in guidelines by the British Thoracic Society [British Thoracic Society, 2008].
Management of acute coronary syndrome
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by NICE [NICE, 2010].
Management of pulmonary oedema
  • These recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010].
Management of acute severe asthma, chronic obstructive pulmonary disease, palpitations, and chest infection
  • The management of these conditions is discussed in the relevant CKS topics.
Management of tension pneumothorax
  • These recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010].
Monitoring
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by NICE [NICE, 2010].

How should I manage people with chest pain not requiring hospital admission?

For people not requiring admission to hospital or referral to a specialist:
Basis for recommendation
Managing musculoskeletal chest pain
  • This recommendation is based on expert opinion from a primary care clinical textbook [Murtagh, 2007].
Managing stable angina
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence [NICE, 2010].
Managing shingles
Managing Bornholm's disease
  • This recommendation is based on expert opinion from a review article Assessment of chest pain in primary care [Schroeder, 2008], produced by the Royal College of General Practitioners, and a primary care clinical textbook [Murtagh, 2007].
Managing psychogenic or non-specific chest pain
  • These recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010], and evidence from a randomized controlled trial [Arnold et al, 2009] and a Cochrane systematic review [Kisely et al, 2010].
    • Providing information sheets may be associated with reduced anxiety and depression in people with non-specific chest pain: this is based on a randomized trial (700 participants) without blinding [Arnold et al, 2009].
    • Psychological treatment may reduce chest pain in people with non-specific chest pain and normal coronary arteries: this is based on a Cochrane systematic review (search date December 2008) of 10 randomized controlled trials investigating 484 people with non-specific chest pain [Kisely et al, 2010].
      • Psychological interventions were associated with a reduction in any chest pain (risk ratio 0.68, 95% CI 0.57 to 0.81).
      • The strongest benefit was seen with cognitive behavioural therapy and within 3 months after the intervention. Benefits were maintained for up to 9 months after the intervention.
      • The results should be viewed with caution as there was significant heterogeneity between the studies (p = 0.00002).

When should I refer a person with chest pain to a specialist?

For people not requiring admission to hospital, appropriately refer them:
  • For an urgent same-day assessment, if the person has:
    • suspected acute coronary syndrome (ACS) and is pain free with:
      • Chest pain in the last 12 hours and a normal electrocardiogram (ECG) and no complications (such as pulmonary oedema).
      • Chest pain in the last 12–72 hours and no complications.
  • Within 2 weeks, if the person has:
    • Suspected ACS and is pain free with chest pain more than 72 hours ago and no complications.
      • Use clinical judgement, interpretation of the 12-lead resting electrocardiogram, and blood troponin level to decide how urgent this referral should be and consider discussing prior management with a cardiologist — see diagnosing ACS.
    • A suspected underlying malignancy (such as lung cancer).
    • A lung or lobar collapse or pleural effusion (if admission is not required), for investigation and treatment of the underlying cause.
  • Routinely, if the person has:
Basis for recommendation
Acute coronary syndrome
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
Stable angina
  • These recommendations are based on expert opinion from the guideline Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin published by NICE [NICE, 2010].
Underlying cancer
  • This recommendation is based on the guideline Referral guidelines for suspected cancer: lung cancer published by NICE [NICE, 2005b].
Lobar or lung collapse or pleural effusion
  • This recommendation is based on what CKS considers to be good clinical practice.
Unclear diagnosis or clear diagnosis but persistent chest pain
  • This recommendation is based on what CKS considers to be good clinical practice and a review article stating that many people with undiagnosed chest pain can be managed in primary care, providing investigations have excluded serious causes of chest pain [Flook et al, 2007].

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Evidence

Supporting evidence

There is no supporting evidence on interventions for chest pain or its underlying causes, because treatments are determined by the underlying cause of chest pain and are dealt with in the relevant CKS topics.

References

All references with links to [Free Full-text] are freely available online to users in the UK. Links to PubMed abstracts are also provided where available. CKS is not responsible for the content of external sites.
Free Full-text links are to dynamic documents that may have been updated since they were originally cited in the CKS topic. All links are checked regularly by CKS Information Specialists and updated to the latest version. Changes in the content of updated documents will not be reflected in the CKS topic text until the next revision.
The following references were cited in February 2011. References dated after this reflect new evidence incorporated since original publication of this topic.
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Search strategy

Further information on the CKS literature searching policy is available in the 'About' section of the CKS website.
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of Chest pain, with additional searches in the following areas:
  • Diagnosis and assessment of chest pain
  • Management of non-cardiac chest pain
  • Management of cardiac chest pain
Search dates
Medline & Embase
Jan 2000 – Dec 2011
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
  • exp Chest Pain/, chest pain.tw, exp Thorax/, exp Pain/
  • exp Acute Coronary Syndrome/
  • exp Diagnostic Techniques, Cardiovascular/, exp "Laboratory Techniques and Procedures"/
  • exp Panic Disorder/, exp Depression/, exp Anxiety/, exp Gastroesophageal Reflux/
Table 1. Key to search terms.
Search commands
Explanation
/
indicates a MeSh subject heading with all subheadings selected
.tw
indicates a search for a term in the title or abstract
exp
indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$
indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Topic specific literature search sources
Sources of guidelines
Sources of systematic reviews and meta-analyses
  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
Sources of randomized controlled trials
  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Drugs in this topic

KnowledgePlus

Links to related knowledge (from CKS KnowledgePlus Drug alerts, Gems from Cochrane, In your area, and the Best Practice in Pathology project) on this topic:

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