Chest Pain (cardiac-sounding*)

STEP 1: Please assess patient for observations, salient history and ECG

STEP 2: Do they have any:

Ongoing cardiac-sounding chest pain (despite simple measures such as 2 puffs s/l GTN)
ST elevation criteria (see below) or new LBBB on ECG
Haemodynamically instability?

YES to any

No, none

Not sure? Please call the Acute GP service to discuss.

ECG criteria for STEMI:

New ST-segment elevation >1mm in two contiguous leads, in all leads except V2 and V3.

In leads V2 and V3, the threshold is:

>2mm for men >40, or > 2.5mm for men < 40,
>1.5mm for women

-OR-

New LBBB

Source: American College of Cardiology (ACC), American Heart Association (AHA), ESC, and the World Heart Federation (WHF)

*cardiac sounding chest pain can involve any of the following (LR+):

Experienced clinical gestalt suggesting cardiac origin (LR+ 4.7 (95% CI: 2.5–8.9))
Chest (or posterior thoracic) pain
Typically 'pressure' or tightness in character (LR+ 1.3 (95% CI: 1.2–1.5))
Radiating to either arm (LR+ 2.3 (95% CI: 1.7–3.1))
Typically lasting longer than 20mins (LR+ 2-3) , less than 10mins is unlikely ACS (LR+ 0.3)
Associated autonomic symptoms (eg sweating) (LR+ 2.0 (95% CI: 1.9–2.2))
Absence of chest wall tenderness (LR+ 2.1 (95% CI: 1.6–2.8))

CIoS Intermediate Care Chest Pain guidelines are based upon recommendations from NICE CG95's CAD background risks, CG185, NEJM's SENIOR-RITA data and in partnership with RCH Cardiology

References

McConaghy, J.R. & Oza, R.S. (2013) ‘Outpatient Diagnosis of Acute Chest Pain in Adults’, JAMA Rational Clinical Examination Series, 309(21), pp. 2213–2222. Available at: https://jamanetwork.com/journals/jama/fullarticle/1697967 (Accessed: 25 February 2025)
Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. doi:10.1001/jama.294.20.2623
Body R, Carley S, McDowell G, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Heart. 2010;96(11):895–901.
Christenson J et al. The predictive value of symptoms for the diagnosis of acute coronary syndromes in the emergency department. Acad Emerg Med. 2006;13(7):635–642.