Chest pain of recent onset requires prompt diagnosis

The NICE guidance on recent onset chest pain urges GPs to assess the nature and timing of acute pain rapidly and arrange urgent admission for suspected acute coronary syndrome. A 12-lead ECG should be performed and treatment commenced with 300 mg aspirin and GTN spray. Other pain relief such as opiates should be considered. However, starting management and recording a resting ECG should not delay transfer to hospital. Patients should be monitored while awaiting transfer. GPs can diagnose stable angina either on clinical assessment alone or combined with diagnostic testing (anatomical testing for obstructive coronary disease and/orfunctional testing for myocardial ischaemia). The presence or absence of the following three factors should be noted: a constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; the discomfort is precipitated by physical exertion; the discomfort is relieved by rest or GTN within about 5 minutes. If all three factors are present the symptoms should be classified as typical angina, two factors atypical angina and one or none of these factors non-anginal chest pain. Once the initial assessment is complete the guidance recommends estimating the likelihood of coronary disease based on risk factors, age, sex and symptom classification. If clinical assessment suggests typical angina and the estimated likelihood of coronary disease is >90%, NICE advises that further diagnostic investigation is unnecessary. These patients should be managed as having angina. If the estimated likelihood of coronary disease is <10% then other non-ischaemic causes of chest pain should be considered.