CHEST PAIN

CHEST PAIN

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Quick reference guide
Issue date: March 2010
Chest pain of recent onset
Assessment and diagnosis of recent onset chest pain or
discomfort of suspected cardiac origin
This guideline partially updates NICE technology appraisal
guidance 73
NICE clinical guideline 95
Developed by the National Clinical Guideline Centre for Acute and Chronic Conditions

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Chest pain of recent onset
About this booklet
This is a quick reference guide that summarises the recommendations NICE has made to the NHS in
`Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of
suspected cardiac origin' (NICE clinical guideline 95).
This guidance updates and replaces recommendation 1.1 of NICE technology appraisal guidance 73 (2003).…read more

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Chest pain of recent onset Contents
Contents
Introduction 3
Person-centred care 3
Key to terms 4
Key priorities for implementation 4
People presenting with acute chest pain 6
People presenting with stable chest pain 10
Further information 15
Introduction
Fast and accurate diagnosis of chest pain or discomfort caused by stable angina or an acute coronary
syndrome (that is, myocardial infarction or unstable angina) is essential so that treatment can be
offered quickly.…read more

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Chest pain of recent onset Key to terms
Key to terms
ACS: acute coronary syndrome MPS with SPECT: myocardial perfusion
CAD: coronary artery disease scintigraphy with single photon emission
computed tomography
CT: computed tomography
MR: magnetic resonance
ECG: electrocardiogram
NSTEMI: non-ST-segment-elevation myocardial
GTN: glyceryl trinitrate
infarction
LBBB: left bundle branch block
SpO2: oxygen saturation by pulse oximetry
MI: myocardial infarction
STEMI: ST-segment-elevation myocardial
infarction
Key priorities for implementation
Presentation with acute chest pain
G Take a resting 12-lead electrocardiogram (ECG) as soon as possible.…read more

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Chest pain of recent onset Key priorities for implementation
G Unless clinical suspicion is raised based on other aspects of the history and risk factors,
exclude a diagnosis of stable angina if the pain is non-anginal (see recommendation 1.3.3.11).
Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
­ continuous or very prolonged and/or
­ unrelated to activity and/or
­ brought on by breathing in and/or
­ associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing.…read more

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People presenting with acute
Chest pain of recent onset chest pain
People presenting with acute chest pain
Check for a suspected ACS
G Check immediately if chest pain is current, or when the last episode was, particularly if in the last
12 hours.
G Check if the chest pain may be cardiac. Consider:
­ history of the pain
- any cardiovascular risk factors
- history of ischaemic heart disease and any previous treatment
- previous investigations for chest pain.…read more

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People presenting with acute
Chest pain of recent onset chest pain
Referral to hospital
ACS suspected?
Yes No
G Start management immediately (box 1) Consider other causes of chest
G Do not delay transfer to hospital pain, including potentially
life-threatening ones
G Current chest No current chest pain
pain or
G Recent ACS and
further chest
pain develops
Chest pain in G Chest pain Signs of
Chest pain
the last 12 12­72 hours more than complications
hours ago 72 hours ago e.g.…read more

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People presenting with acute
Chest pain of recent onset chest pain
In hospital
Initial assessment (box 3)
ECG findings Troponin levels
G Regional ST-segment If initial troponin is
elevation or raised:
G Presumed new left G consider other causes
bundle branch block (LBBB)? e.g.…read more

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People presenting with acute
Chest pain of recent onset chest pain
Box 2 Monitor until diagnosis
G Include:
­ exacerbations of pain and/or other symptoms
­ pulse and blood pressure
­ heart rhythm
­ oxygen saturation by pulse oximetry
­ repeated resting 12-lead ECGs
­ checking pain relief is effective.
G Decide how often this should be done.…read more

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People presenting with stable
Chest pain of recent onset chest pain
People presenting with stable chest pain
G Angina can be diagnosed based on clinical assessment alone or clinical assessment plus diagnostic testing.
G Manage risk factors for cardiovascular disease8 if chest pain is not stable angina.…read more

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