Chest Pain: Assessment of Patients with Suspected Cardiac Chest Pain

Key points

• Suspected ACS — immediate management: glyceryl trinitrate + aspirin 300 mg (NICE: do NOT give other antiplatelets such as clopidogrel outside hospital).
• Do not routinely give oxygen — only if SpO2 < 94%.
• Perform ECG as soon as possible but do not delay transfer; a normal ECG does not exclude ACS.
• Stable exertional chest pain pathway: assess typicality; NICE 2016 recommends CT coronary angiography first-line for stable chest pain assessment.
• Referral by timing: current chest pain or chest pain in the last 12 hours with an abnormal ECG → emergency admission; chest pain 12-72 hours ago → refer to hospital the same day; chest pain > 72 hours ago → full assessment with ECG and troponin before deciding further action
• Oxygen is not routine: monitor SpO2 with pulse oximetry as soon as possible (ideally before admission); offer oxygen only if SpO2 < 94% (target 94-98%), or target 88-92% in COPD patients at risk of hypercapnic respiratory failure until blood gas analysis is available
• NICE define anginal pain as: constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms · precipitated by physical exertion · relieved by rest or GTN in about 5 minutes
• All 3 features = typical angina · 2 features = atypical angina · 1 or none = non-anginal chest pain

Decision points in this pathway

• Current chest pain, or chest pain in the last 12 hours with an abnormal ECG?
• Chest pain 12-72 hours ago?
• Stable angina cannot be excluded by clinical assessment alone (symptoms consistent with typical/atypical angina OR ECG changes)?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.