History and exam
Key diagnostic factors
common
chest pain
Check immediately whether the patient currently has chest pain.[73]
If the patient is currently free from chest pain, ask when their last episode of pain occurred, particularly if they have had pain in the last 12 hours.[73]
Ask when the patient’s last episode of chest pain started because this will determine the timing of high-sensitivity troponin testing.[73]
Consider the following to determine whether the chest pain is likely to be cardiac:[73]
The history and character of the patient’s chest pain[1][73]
Useful points to cover include:
Whether the patient has experienced this type of pain before
The nature, severity, and duration of pain
Often cardiac chest pain is a retrosternal sensation of pain, pressure, or heaviness radiating to the left arm, both arms, right arm, neck, or jaw, which may be intermittent or persistent[73]
Ask when the patient’s chest pain started because this will determine the timing of high-sensitivity troponin testing[1][73]
If symptoms are intermittent, it is important to ask when the last episode of pain occurred
Any associated symptoms.[73]
In the community, refer all patients to hospital as an emergency if you suspect an acute coronary syndrome (ACS) and they:[73]
Currently have chest pain
Are currently pain-free, but have had chest pain within the last 12 hours and a resting 12-lead ECG is abnormal or unavailable
Have had a recent ACS (confirmed or suspected) and develop further chest pain.
Practical tip
Patients may also describe chest pain as pressure, tightness, or a burning sensation.[1]
risk factors for cardiovascular disease
Risk factors for cardiovascular disease include:[73]
Diabetes[2]
Hyperlipidaemia[75]
Hypertension[75]
Metabolic syndrome
Renal impairment[2]
Peripheral arterial disease[2]
A history of ischaemic heart disease and any previous treatment[73]
Obesity
Advanced age
Cocaine use
Physical inactivity
Family history of premature coronary artery disease (<60 years of age).
Other diagnostic factors
common
nausea and vomiting
Nausea and vomiting are common features. May be the only symptom.
Non-ST-elevation myocardial infarction (NSTEMI; and other ACS) should be suspected in any patient with chest pain, which includes pain in other areas (e.g., the arms, back or jaw), that is associated with nausea and vomiting, marked sweating or diaphoresis, and/or breathlessness, or particularly a combination of these.[73]
arrhythmias
Get urgent input from a senior colleague or cardiology if the patient has a life-threatening arrhythmia (ventricular tachycardia or ventricular fibrillation) to arrange immediate invasive coronary angiography (with the intent to perform revascularisation).[1] Do not wait for the results of troponin testing.[1] See Sustained ventricular tachycardias.
uncommon
marked sweating
The patient may have significant sweating due to high sympathetic drive.[73][76]
NSTEMI (and other ACS) should be suspected in any patient with chest pain, which includes pain in other areas (e.g., the arms, back, or jaw) that is associated with nausea and vomiting, marked sweating or diaphoresis, and/or breathlessness, or particularly a combination of these.[73][76]
epigastric pain
Be aware of presentations where chest pain is not the predominant feature (chest-pain equivalent symptoms) such as epigastric pain/indigestion-like symptoms. These are more common in older patients, women, and patients with diabetes.[1]
dyspnoea
Isolated dyspnoea can occur, particularly in older patients, women, and patients with diabetes.[1]
syncope
The patient may have syncope. This occurs more frequently in older patients, women, and patients with diabetes.[1]
back pain
Women may present with middle/upper back pain.
abnormal heart sounds
A new systolic murmur may be present due to ischaemic mitral regurgitation, which is associated with a poor prognosis, or a mechanical complication (e.g., papillary muscle rupture or ventricular septal defect).
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