History and exam

Key diagnostic factors

common

chest pain

Check immediately if the patient currently has chest pain.[63]

Suspect NSTEMI (and other acute coronary syndromes [ACS]) in any patient presenting with chest pain, which includes pain in other areas (e.g., the arms, back, or jaw), that:[63]

  • Lasts longer than 15 minutes

  • Is associated with nausea and vomiting, marked sweating, and/or breathlessness, or particularly a combination of these[63]

  • Is associated with haemodynamic instability

  • Is either new in onset or occurs as sudden worsening of known stable angina (i.e., recurrent episodes of chest pain lasting longer than 15 minutes that occur frequently and with little or no exertion).

Consider the history and character of the patient’s chest pain to determine whether it is likely to be cardiac.[63] 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.[7]

    • Ask when the patient’s chest pain started because this will determine the interpretation of high-sensitivity troponin testing.[63]

    • If symptoms are intermittent, it is important to ask when the last episode of pain occurred.[63]

  • Any associated symptoms.

Practical tip

Patients may also describe chest pain as pressure, tightness, heaviness, or a burning sensation.[7]

Practical tip

Do not use a trial of glyceryl trinitrate (with subsequent relief of chest pain) to support a clinical suspicion of myocardial ischaemia as similar improvement may occur in other causes of acute chest pain.[7][63]

In the community, refer all patients to hospital as an emergency if you suspect an ACS and they:[63]

  • 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.

risk factors for cardiovascular disease

Risk factors for cardiovascular disease include:

  • Diabetes[1]

  • Hyperlipidaemia[66]

  • Hypertension[66]

  • Metabolic syndrome

  • Renal impairment[1]

  • Peripheral arterial disease[1]

  • A history of ischaemic heart disease and any previous treatment[63]

  • Obesity

  • Advanced age

  • Smoking

  • Cocaine use

  • Physical inactivity

  • Family history of premature coronary artery disease (<60 years).

marked sweating

Significant sweating is a common feature due to high sympathetic drive.[63][67]

Suspect NSTEMI (and other ACS) 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, and/or breathlessness, or particularly a combination of these.[63]

uncommon

cardiogenic shock

Get urgent input from a senior colleague or cardiology if the patient is haemodynamically unstable (low blood pressure or shock) to arrange immediate invasive coronary angiography (with the intent to perform revascularisation).[61][62] Do not wait for the results of troponin testing.[7] See Shock.

acute heart failure

Get urgent input from a senior colleague or cardiology if the patient has left ventricular failure to arrange immediate invasive coronary angiography (with the intent to perform revascularisation).[61][62] Do not wait for the results of troponin testing.[7] See Acute heart failure.

Other diagnostic factors

common

nausea and vomiting

Nausea and vomiting are common features.

Suspect NSTEMI (and other ACS) 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, and/or breathlessness, or particularly a combination of these.[63]

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).[7] Do not wait for the results of troponin testing.[7] See Sustained ventricular tachycardias.

uncommon

heart murmur

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).

epigastric pain

Be aware of presentations where chest pain is not the predominant feature (chest-pain equivalent symptoms) such as epigastric pain and indigestion-like symptoms. These are more common in older patients, women, and patients with diabetes.[7]

dyspnoea

Isolated dyspnoea can occur, particularly in older patients, women, and patients with diabetes.[7]

syncope

The patient may have syncope. This occurs more frequently in older patients, women, and patients with diabetes.[7]

back pain

Be aware that women are more likely to present with middle/upper back pain.

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