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10StepsBeforeyouReferfor:ChestPain
SudhakarAllamsetty,SreekalaSeepana,KathrynE.Griffith
BrJCardiol.200916(2):8084.

Introduction
Chestpainisacommonpresentationingeneralpractice.Eachyearabout1%oftheUKpopulationvisittheirGPwith
chestpain. [1]TheaverageGPwillsee,onaverage,fournewcasesofanginaeachyear. [2]TheEuroheartsurveyof
newlydiagnosedstableanginapatientsshowedthattheincidenceofdeathandmyocardialinfarction(MI)was2.3/100
patientyears.ThisisincreasedinpatientswithapreviousMI,shorthistory,moreseveresymptomsandwithheart
failureorothercomorbidities,suchasdiabetes. [3]Therecognitionofthesepatientsasathighriskforcardiovascular
eventshasledtotheimprovementofdiagnosisandmanagementofangina.Rapidaccesschestpainclinicshavebeen
developedtoallowquickassessmentofpatientswithnewonsetanginaaspartofaNationalServiceFrameworkfor
coronaryarterydisease.

1.TakeaDetailedHistory
Acarefulhistoryremainsthecornerstoneofthediagnosisofanginapectoris. [4]Therearesometypicalcharacteristics
ofchestpainthatincreasethelikelihoodthatthepainisanginaandcausedbyunderlyingcoronaryheartdisease
(CHD). [5]
Stableanginaischaracterisedbythetypeofdiscomfortandlocation(): [6]itiselicitedbyphysicalexertionoremotion
andrelievedbyrestorglyceryltrinitrate(GTN).Durationisshortanditisworseincoldweatherorafterameal().
Table1.ClinicalClassificationofChestPain[6]

Typicalangina(definite)
Meetsthreeofthefollowingcharacteristics:
1. Substernalchestdiscomfortofcharacteristicqualityandduration
2. Provokedbyexertionoremotionalstress
3. Relievedbyrestand/orglyceryltrinitratespray
Atypicalangina(possible)
Meetstwoofthesecharacteristics
Noncardiacchestpain
Meetsoneornoneofthesecharacteristics
Table2.StableAnginaDescriptions

Typeofdiscomfort,oftentight,dullorheavy
Locationinleftchest,canradiatetojaw,shoulder,back,arms
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Elicitedbyphysicalexertionoremotionandrelievedbyrestorglyceryltrinitrate(GTN)although
oesophagealspasmmayalsorespondtoGTN
Durationofseveralminutesafterexertionorstresshasstopped
Associatedfactors,forexampleworseincoldweatherorafterameal
Inunstableangina,thesymptomsaremoresevere,moreprolonged,morefrequent,andmayoccuratlowerthresholds
orevenatrest.Patientswhoareconsideredtohaveunstableanginashouldbeadmittedtohospitalacutely,andtheir
managementisnotincludedhere.

2.ConsiderNoncardiacCausesofChestPain
ThemostcommoncausesofchestpainseenintheGPsurgeryarenoncardiac().Theyareusuallydifferentiatedby
carefulhistorytaking.Differentialdiagnosesincludeoesophagealdisorders,suchasgastrooesophagealrefluxor
oesophagealdysmotilitysuggestedbythecharacterofthepainwithepigastricburning,acidreflux,andreliefwith
antacids.
Table3.TheNoncardiacCausesofChestPain

gastrooesophagealreflux
oesophagealdysmotility
chestinfection
pulmonaryembolism
lungtumour
musculoskeletalpain(Tietzsyndrome)
referredpainfromthethoracicspine
biliarypain
psychologicalcauses
Pleuralpainmaybecausedbyinfection,pulmonaryembolismortumour.Thecharacterofthepainisimportantwith
elucidationofpulmonarysymptoms.Musculoskeletalpain,suchaswithTietzsyndrome,issuggestedbyapleuritic
characterandlocaltenderness.Referredpainfromthethoracicspinecanbesuggestedbyprevioushistory,trauma
andlocaltenderness.Biliarypainwithepigastricorrighthypochondrialdiscomfort,isworsewithfattyfoodsand
associatedwithnausea.
Psychologicalcausesincludeanxiety,panicattacks,anddepression.Somaticsymptomsofpsychologicaldisordersare
verycommon,however,itisalsoimportanttorememberthattheonsetofanginaitselfmayinducesignificantanxiety.
Anginalpainisnotusuallysharporstabbinginnature,itisnotusuallyinfluencedbyrespiration,itisnotfleetingnor
doesitlastallday.ScottishIntercollegiateGuidelinesNetwork(SIGN)guidelines[5]recommendthatifthediagnosisis
uncertainthenpractitionersshouldnotgivetheimpressionthatthepatienthasangina,whichmayleadtothe
developmentofadversefalsebeliefs.EarlyspecialistopinionthroughRapidAccessChestPainClinicmayhelpto
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disputeaninaccuratediagnosisandreducetheriskofthesefalsebeliefsdeveloping.Lowriskpatientswithatypical
symptomsshouldbemanagedinprimarycarewherepossible. [5]Itisimportanttoexplainsymptomsandconcerns,
andprovidereassurancewherenecessary.CorrectmanagementbyaconfidentGPmaybothreducemorbidityandthe
needforreferral.

3.EstablishtheRiskFactors:HowLikelyisitThatYourPatienthasCHD?
Riskfactorscanbemodifiableornonmodifiable.Nonmodifiableriskfactorsincludeincreasingageandsex.About
85%ofpeoplewhodieofcoronaryarterydiseaseareaged65yearsorolder. [7]Menhaveagreaterriskofpremature
heartdiseasethanwomen. [7]
TheriskofcardiovasculardiseaseishigherinethnicgroupssuchasSouthAsians,andthoseofAfricanCaribbean
origin.Thisincreasedriskispartlyduetohigherratesofhighbloodpressure,obesityanddiabetesinthese
populations.Riskofcardiovasculardiseaseincreasesifthereisapositivefamilyhistoryofprematurecardiovascular
diseaseinafirstdegreerelative.ThisisdefinedasahistoryofprematureCHDunderage55infathers,sonsor
brothers,orunderage65inmothers,daughtersorsisters. [8]
Modifiableriskfactorsincludesmoking,whichisthemostimportantpreventableriskfactorforcardiovasculardisease
andstroke.Increaseinweightandlackofphysicalexercisecontributetocardiovascularrisk,partiallyrelatedto
associationwithtype2diabetes.Diabetesmellitusisconsideredbysometobeacardiovasculardiseaseequivalent.
Hightotalcholesterolandlowdensitylipoprotein(LDL)cholesterolwithlowhighdensitylipoprotein(HDL)cholesterol
aremodifiableriskfactors.Highsaltconsumptionandadietrichinsaturatedfatcancontributetocardiovascular
disease.Elevatedbloodpressureisassociatedwithincreasedheartattackandstrokes.Excessalcoholconsumption
canleadtoincreasedbloodpressure,heartfailureandstroke.

4.PerformaPhysicalExamination
Thisisanimportantstep[9]beforereferral()becauseitmayidentifyconditionsthatcanprecipitateangina(suchas
anaemiaorhyperthyroidism)andconditionsotherthanCHDthatcanpresentwithangina(aorticstenosis/hypertrophic
obstructivecardiomyopathy).Theremayalsobefindingsthatwouldmakeatreadmilltestunsuitable,suchas
uncontrolledbloodpressureoraorticstenosis.
Table4.WhattoIncludeinPatientExamination

Weight,heightandcalculationofbodymassindex(BMI)
Waistcircumferencetoevaluatepresenceofthemetabolicsyndrome
Pulserateandrhythm
Bloodpressure
Presenceofmurmurs,especiallyaorticstenosis
Evidenceofhyperlipidaemiawithxanthelasmaortendonxanthomata
Evidenceofperipheralvasculardiseasewithabsentfootpulses,bruits,skinchanges,hairloss
Evidenceofanaemiaorthyroiddisease

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Acomprehensiveexaminationshouldincludeweightandheighttoallowcalculationofbodymassindex,andwaist
circumferencetoevaluatepresenceofthemetabolicsyndrome.Recordthepulserate,rhythmandbloodpressure.
Listenforthepresenceofmurmurs,especiallyaorticstenosis.Lookforevidenceofhyperlipidaemiawithxanthelasma
ortendonxanthomata.Examineforevidenceofperipheralvasculardiseasewithabsentfootpulses,bruits,skin
changesorhairloss.Lookforevidenceofanaemiaorthyroiddisease.

5.CarryOuttheRelevantInvestigation
WherethereisalowindexofsuspicionofCHD,thenitisnotrecommendedthatthepatientundergoesfurthertests.
[9,10]

Forpatientsconsideredathigherrisk,thefollowingtestsarerecommended.Afullbloodcount,serumcreatinineor
estimatedglomerularfiltrationrate(eGFR),afastinglipidprofileandbloodglucose.Thyroidfunctiontestsshouldbe
carriedoutifthereisclinicalsuspicionofthyroiddisease.
Aresting12leadelectrocardiogram(ECG)shouldberecordedinanyonewithsuspectedanginatoprovideinformation
onrateandheartrhythmtocheckforatrialfibrillationorheartblock,andtocheckforsignsofmyocardialischaemia,
hypertrophy,orpreviousMI.SomeECGabnormalitiesmayexcludepatientsfromadiagnostictreadmilltestsuchas
leftbundlebranchblock(LBBB)andatrialfibrillation.AnormalECGdoesnotexcludeanginaasmorethan50%of
peoplewithstableanginahaveanormalrestingECG. [11]
ChestXrayisnotusefulintheinitialevaluationofchestpain,unlessthereisahistorysuggestiveofheartfailure,
pulmonarydiseaseorvalvularpathology.

6.EstimatetheCardiovascularDiseaseRisk
Usingtheinformationobtainedbytherecommendedassessment,allpatientsshouldhavetheirriskofcardiovascular
diseaseestimatedusingariskestimationtool.AtpresenttheJointBritishSocieties(JBS2)riskestimationtool[12]is
recommendedandtheASSIGNtoolinScotland.
Theuseofthesechartsisnotappropriateforpatientswithpreexistingcardiovasculardisease,chronickidneydisease
andproteinuria,familialhypercholesterolaemiaorotherinheriteddyslipidaemia,ortype1andtype2diabetesmellitus,
forwhomtheUKProspectiveDiabetesStudy(UKPDS)riskassessmenttoolmaybeused.
Cardiovascularriskishigherthanindicatedinthechartsforthosewithafamilyhistoryofprematurecardiovascular
diseaseorstroke(malefirstdegreerelativesaged<55yearsandfemalefirstdegreerelativesaged<65years),which
increasestheriskbyafactorof1.5, [8]and2.0timeswithtwofirstdegreerelatives.ItisalsohigherinthoseofSouth
Asianbackgroundwheretheincreasedriskformenis1.4times,inthepresenceofleftventricularhypertrophy(LVH)
ontheECG,andinthosewithraisedtriglyceridelevels.Specialconsiderationisrequiredforthosewithchronickidney
diseasewithoutproteinuria,whereacorrectionfactorisnotyetidentified,womenwithprematuremenopauseand
thosewhoarenotyetdiabetic,buthaveanimpairedfastingglucose.

7.GiveLifestyleAdvice
Anyonewithanginashouldbeadvisedtostopsmoking.Smokingincreasestheriskofsmallvesseldiseaseandtherisk
ofdyingfromit,andriskisincreasedasmorecigarettesaresmoked. [10]Riskofacardiovasculareventfallsfromthe
firstdaythepatientstops.Patientsmayneedreferraltospecialistsmokingcessationservicesandnicotine
replacementtherapy.
TheMediterraneandietisrecommendedwithfiveportionsoffruitandvegetables,andmonounsaturatedfatsfrom
oliveandrapeseedoils.Peopleathighriskofcardiovasculardiseasearerecommendedtoconsumeatleasttwo
portionsoffishperweek,includingoneportionofoilyfish.Omega3fattyacidsarealsofoundinflaxseed,almonds
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andwalnuts.
Weightlossisrecommendedforallthosewhoareobeseoroverweight.Moderateexercisefor30minutesaday,on
mostdays,withinthelimitssetbytheirsymptoms,shouldbeadvised. [10]Patientswithcardiovasculardiseasewillbe
offeredascreeningquestionnaireforanxietyanddepression,andmayneedadvicetomanagestress,relaxation
techniquesandsettingrealisticgoals.
HoldersofLargeGoodsVehicle(LGV)andPassengerCarryingVehicle(PCV)licenceswithnewonsetofangina
shouldnotifytheDriverandVehicleLicensingAgency(DVLA)andstopdrivingtheirvehicle.Holdersofanordinary
drivinglicencemaystilldriveprovidingthatsymptomsarecontrolled,butmustinformtheirmotorvehicleinsurance
company.Peoplewhooperateheavymachinerymayalsobeaffected. [13]
Itisimportanttoreassurethatanginadoesnotdamagetheheart,however,patientsshouldbeadvisedabouttherisk
andsymptomsofheartattackandwhentocall999. [10]

8.TreatmenttoControlSymptomsandReduceCardiovascularRisk
Therearetwoarmstotreatment,whichshouldbecommencedifthereisahighsuspicionofcardiovasculardisease.
SublingualGTNshouldbeprescribedtoabortattacks,ortoprovideashortperiodofprophylaxiswhiledoingactivities
likelytoprecipitateangina.IfanginaisnotrelievedbyGTNtreatmenttheyshouldbeadvisedtoseekurgentmedical
advice.
Abetablockershouldbecommencedasfirstlinetreatmentforlongtermsymptomcontrol.
Acalciumchannelblocker,diltiazem,isusuallythefirstchoicewhereabetablockeriseithercontraindicatedornot
tolerated.
Aspirin75mgshouldbestartedifcardiovascularrisk>20%,orifthereisahighsuspicionofCHDandbloodpressure
<150/90mmHg.Ifthereisahighriskofgastrointestinaladverseeffectsitcanbeusedincombinationwithaproton
pumpinhibitor.Clopidogrel75mgisanalternativeoption.
Statinsshouldbeoffereddependingonthecardiovascularriskforprimarypreventionandforallpatientswhofitinto
secondaryprevention.Itisrecommendedtostartwithsimvastatin40mg. [8]

9.ConsideraRapidAccessChestPainClinicReferral
Theseclinicsofferopenaccessreferralforpatientswithnewonsetofchestpainandpatientsshouldbeseenwithin
twoweeks.Theymaybenurseortechnicianled,andusuallyinvolvethepatienthavinganexerciseECG,providing
valuableprognosticinformation.
PeopleshouldnotbereferredforanexerciseECGiftheyareonmaximalmedicaltreatmentandstillhavesymptoms,
thediagnosisofCHDisunlikely,oriftheyarephysicallyincapableoftakingthetest.Patientswhomayhaveaortic
stenosisorcardiomyopathyarenotsuitable.Thereisnopointinreferringpatientsinwhomtheresultsofanexercise
ECGwouldnotaffectmanagement [10]orwhodonotwishfurtherinvestigationoftheirpain.
Themanagementofpatientswithchestpainfromreferraltodefinitivetreatment,includingbypasssurgery,isnow
includedwithinan18week'commissioningpathway'.Duringthistime,patientswillbesubjectedtoamultitudeof
investigationsandtreatments.Theprimarycareteamhasakeyroleinsupportingthepatientandshouldbeclosely
involvedineducationandlifestylechangestopromotethebestpossibleoutcome.

10.ConsiderReferraltoaCardiologist
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Notallpatientsshouldbereferred,andsomemaynotwishfurtherinvestigation,however,thoseinthefollowing
groupsshouldbeconsideredforearlyreferraltoacardiologist.Thiswouldincludepeoplewithnewonsetofchestpain,
whohavehadapreviousMI,coronaryarterybypassgrafting,orpercutaneoustransluminalcoronaryangioplastyalso
peoplewhoseemtohaveECGevidenceofapreviousMI,orothersignificantabnormalitypeoplewhofailtorespond
tomedicaltreatmentandpeoplewhohaveanejectionsystolicmurmursuggestingaorticstenosis.
Somepeoplewiththefollowingsymptomsmayhaveanacutecoronarysyndromeandshouldbeconsideredfor
hospitaladmission.Theyincludethosewithapainonminimalexertion,painatrest(whichmayoccuratnight),and
thoseinwhomanginaseemstobeprogressingrapidlydespiteincreasingmedicaltreatment.EvidenceofanMIinthe
ECGordynamicchangessuggestiveofischaemiashouldbeurgentlytransferredtohospital.
References

1. O'TooleL.Angina(stable).ClinEvid200513:629.
2. LewinRJ,FurzeG,RobinsonJetal.Arandomisedcontrolledtrialofaselfmanagementplanforpatientswith
newlydiagnosedangina.BrJGenPract200252:1946,199201.
3. DalyCA,DeStavolaB,SendonJLetal.PredictingprognosisinstableanginaresultsfromtheEuroheart
surveyofstableangina:prospectiveobservationalstudy.BMJ2006332:2627.
4. BruyninckxR,AertgeertsB,BruyninckxPetal.Signsandsymptomsindiagnosingacutemyocardialinfarction
andacutecoronarysyndrome:adiagnosticmetaanalysis.BrJGenPract200858:10511.
5. ScottishIntercollegiateGuidelinesNetwork.Managementofstableangina.Anationalclinicalguideline.
Edinburgh:SIGN,2007guideline96.
6. DiamondGA.Aclinicallyrelevantclassificationofchestdiscomfort.JAmCollCardiol19831(2Pt1):5745.
7. BritishHeartFoundationStatisticsWebsite.www.heartstats.org
8. NationalInstituteforHealthandClinicalExcellence.CG67Lipidmodification:NICEguideline.London:NICE,
2008.
9. CKSLibrary.www.ckslibrary.nhs.uk
10. DepartmentofHealth.18weekcommissioningpathwaychestpainsupplementaryinformationversion1.2.
London:DoH,July2007.
11. SnowV,BarryP,FihnSDetal.Evaluationofprimarycarepatientswithchronicstableangina:guidelinesfrom
theAmericanCollegeofPhysicians.AnnInternMed2004141:5764.
12. BritishCardiacSociety,BritishHypertensionSociety,DiabetesUK,HEARTUK,PrimaryCareCardiovascular
Society,StrokeAssociation.JBS2:JointBritishSocieties'guidelinesonpreventionofcardiovasculardiseasein
clinicalpractice.Heart200591(Suppl5):v1v52.
13. DriverandVehicleLicensingAgency.www.dvla.gov.uk
BrJCardiol.200916(2):8084.2009SherborneGibbsLtd.

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