Recent-onset Chest Pain of Suspected Cardiac Origin: Assessment and Diagnosis in Secondary Care

Overview

This specialist Guidelines summary covers assessing and diagnosing recent chest pain in people aged 18 and over and managing symptoms while a diagnosis is being made. It aims to improve outcomes by providing advice on tests (electrocardiogram [ECG], high-sensitivity troponin tests, multislice computed tomography [CT] angiography, functional testing) that support healthcare professionals to make a speedy and accurate diagnosis.

NICE has also produced a guideline on managing acute coronary syndromes.

Please refer to the full guideline for further information on providing information for people with chest pain and initial assessment and referral to hospital, including recommendations on ECGs.

This summary is intended for use by cardiologists, acute and emergency medicine specialists, and laboratory services in a secondary care setting.

People Presenting with Acute Chest Pain

Immediate Management of a Suspected Acute Coronary Syndrome

Management of acute coronary syndrome (ACS) should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances.

• Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected 
• Offer people a single loading dose of 300 mg aspirin as soon as possible, unless there is clear evidence that they are allergic to it
  • if aspirin is given before arrival at hospital, send a written record that it has been given with the person
  • only offer other antiplatelet agents in hospital. Follow the NICE guideline on acute coronary syndromes 
• Do not routinely administer oxygen, but monitor oxygen saturation (SpO₂) using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
  • people with SpO₂ of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO₂ of 94% to 98%
  • people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO₂ of 88% to 92% until blood gas analysis is available
• Monitor people with acute chest pain, using clinical judgement to decide how often this should be done, until a firm diagnosis is made. This should include:
  • exacerbations of pain and/or other symptoms
  • pulse and blood pressure
  • heart rhythm
  • SpO₂ by pulse oximetry
  • repeated resting 12-lead ECGs, and
  • checking pain relief is effective 
• Manage other therapeutic interventions using the NICE guideline on acute coronary syndromes. 

Assessment in Hospital for People With a Suspected Acute Coronary Syndrome

• Take a resting 12-lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see the section on Use of Biochemical Markers for Diagnosis of an Acute Coronary Syndrome) on arrival in hospital 
• Carry out a physical examination to determine:
  • haemodynamic status
  • signs of complications, for example, pulmonary oedema, cardiogenic shock, and
  • signs of non-coronary causes of acute chest pain, such as aortic dissection 
• Take a detailed clinical history unless an ST segment elevation myocardial infarction (STEMI) is confirmed from the resting 12-lead ECG (that is, regional ST-segment elevation or presumed new left bundle branch block [LBBB]). Record:
  • the characteristics of the pain
  • other associated symptoms
  • any history of cardiovascular disease
  • any cardiovascular risk factors, and
  • details of previous investigations or treatments for similar symptoms of chest pain. 

Use of Biochemical Markers for Diagnosis of an Acute Coronary Syndrome

• Do not use high-sensitivity troponin tests for people in whom ACS is not suspected 
• For people at high or moderate risk of MI (as indicated by a validated tool), perform high-sensitivity troponin tests as recommended in the NICE diagnostics guidance on myocardial infarction (DG40) 
• For people at low risk of MI (as indicated by a validated tool):
  • perform a second high-sensitivity troponin test as recommended in the NICE diagnostics guidance on myocardial infarction (DG40) if the first troponin test at presentation is positive
  • consider performing a single high-sensitivity troponin test only at presentation to rule out non-STEMI (NSTEMI) if the first troponin test is below the lower limit of detection (negative) 
• Ensure that patients understand that a detectable troponin on the first high-sensitivity test does not necessarily indicate that they have had an MI 
• Do not use biochemical markers such as natriuretic peptides and high-sensitivity C-reactive protein to diagnose an ACS 
• Do not use biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin) as opposed to markers of necrosis when assessing people with acute chest pain 
• When interpreting high-sensitivity troponin measurements, take into account:
  • the clinical presentation
  • the time from onset of symptoms
  • the resting 12-lead ECG findings
  • the pre-test probability of NSTEMI
  • the length of time since the suspected ACS
  • the probability of chronically elevated troponin levels in some people
  • that 99th percentile thresholds for troponin I and T may differ between sexes. 

Making a Diagnosis

• When diagnosing MI, use the universal definition of MI. This is the detection of rise and/or fall of cardiac biomarkers values (preferably cardiac troponin [cTn]) with at least one value above the 99th percentile of the upper reference limit and at least one of the following:
  • symptoms of ischaemia
  • new or presumed new significant ST-segment-T wave (ST-T) changes or new LBBB
  • development of pathological Q waves in the ECG
  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
  • identification of an intracoronary thrombus by angiography 
• When a raised troponin level is detected in people with a suspected ACS, reassess to exclude other causes for raised troponin (for example, myocarditis, aortic dissection, or pulmonary embolism) before confirming the diagnosis of ACS 
• When a raised troponin level is detected in people with a suspected ACS, follow the NICE guideline on acute coronary syndromes until a firm diagnosis is made. Continue to monitor
• When a diagnosis of ACS is confirmed, follow the NICE guideline on acute coronary syndromes 
• Reassess people with chest pain without raised troponin levels and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac
  • if myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline (see the section on People Presenting with Stable Chest Pain). Use clinical judgement to decide on the timing of any further diagnostic investigations 
• Do not routinely offer non-invasive imaging or exercise ECG in the initial assessment of acute cardiac chest pain
• Only consider early chest computed tomography (CT) to rule out other diagnoses such as pulmonary embolism or aortic dissection, not to diagnose ACS 
• Consider a chest X-ray to help exclude complications of ACS such as pulmonary oedema, or other diagnoses such as pneumothorax or pneumonia 
• If an ACS has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example, the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults. 

People Presenting with Stable Chest Pain

This section of the guideline addresses the assessment and diagnosis of intermittent stable chest pain in people with suspected stable angina.

• Exclude a diagnosis of stable angina if clinical assessment indicates non-anginal chest pain (see Making a Diagnosis Based on Clinical Assessment) and there are no other aspects of the history or risk factors raising clinical suspicion 
• If clinical assessment indicates typical or atypical angina (see Making a Diagnosis Based on Clinical Assessment), offer diagnostic testing (see the sections on Diagnostic Testing for People in whom Stable Angina Cannot be Excluded by Clinical Assessment Alone, Additional Diagnostic Investigations, and Use of Non-invasive Functional Testing for Myocardial Ischaemia).

Clinical Assessment

• Take a detailed clinical history documenting:
  • the age and sex of the person
  • the characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain
  • any associated symptoms, such as breathlessness
  • any history of angina, MI, coronary revascularisation or other cardiovascular disease, and
  • any cardiovascular risk factors 
• Carry out a physical examination to:
  • identify risk factors for cardiovascular disease
  • identify signs of other cardiovascular disease
  • identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy), and
  • exclude other causes of chest pain. 

Making a Diagnosis Based on Clinical Assessment

• Assess the typicality of chest pain as follows:
  • presence of three of the features below is defined as typical angina
  • presence of two of the three features below is defined as atypical angina
  • presence of one or none of the features below is defined as non-anginal chest pain

Anginal pain is:

• 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 within about 5 minutes 
• Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in men and women
• Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in ethnic groups 
• Take the following factors, which make a diagnosis of stable angina more likely, into account when estimating people's likelihood of angina:
  • age
  • whether the person is male
  • cardiovascular risk factors, including:
    • a history of smoking
    • diabetes
    • hypertension
    • dyslipidaemia
    • family history of premature coronary artery disease (CAD)
  • other cardiovascular disease
  • history of established CAD, for example, previous MI, coronary revascularisation 
• 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 Making a Diagnosis Based on Clinical Assessment). 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

Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain) 

• Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD 
• Arrange blood tests to identify conditions which exacerbate angina, such as anaemia, for all people being investigated for stable angina 
• Only consider chest X-ray if other diagnoses, such as a lung tumour, are suspected 
• If a diagnosis of stable angina has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example, the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults 
• For people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation 
• Do not rule out a diagnosis of stable angina on the basis of a normal resting 12-lead ECG 
• Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment (see Making a Diagnosis Based on Clinical Assessment) unless there are resting ECG ST-T changes or Q waves 
• A number of changes on a resting 12-lead ECG are consistent with CAD, and may indicate ischaemia or previous infarction. These include:
  • pathological Q waves in particular
  • LBBB
  • ST-segment and T wave abnormalities (for example, flattening or inversion)
    • note that the results may not be conclusive
    • consider any resting 12-lead ECG changes together with people's clinical history and risk factors 
• For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography) in whom stable angina cannot be excluded based on clinical assessment alone, see the recommendation about functional testing in the next section
• Consider aspirin only if the person's chest pain is likely to be stable angina, until a diagnosis is made. Do not offer additional aspirin if there is clear evidence that people are already taking aspirin regularly or are allergic to it 
• Follow the NICE guideline on stable angina while waiting for the results of investigations if symptoms are typical of stable angina. 

Diagnostic Testing for People in Whom Stable Angina Cannot Be Excluded by Clinical Assessment Alone

The Guideline Development Group emphasised that the recommendations in this guideline are to make a diagnosis of chest pain, not to screen for CAD. Most people diagnosed with non-anginal chest pain after clinical assessment need no further diagnostic testing. However, in a very small number of people, there are remaining concerns that the pain could be ischaemic.

• Include the typicality of anginal pain features (see Making a Diagnosis Based on Clinical Assessment) in all requests for diagnostic investigations and in the person's notes 
• Use clinical judgement and take into account people's preferences and comorbidities when considering diagnostic testing 
• Offer 64-slice (or above) CT coronary angiography if:
  • clinical assessment (see Making a Diagnosis Based on Clinical Assessment) indicates typical or atypical angina, or
  • clinical assessment indicates non-anginal chest pain, but 12-lead resting ECG has been done and indicates ST-T changes or Q waves 
• For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography), offer non-invasive functional testing when there is uncertainty about whether chest pain is caused by myocardial ischaemia. (See Use of Non-Invasive Functional Testing for Myocardial Ischaemia.) An exercise ECG may be used instead of functional imaging 

See also the NICE medical technology guidance on HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography. Using HeartFlow FFR_CT may avoid the need for invasive coronary angiography and revascularisation for some patients.

Additional Diagnostic Investigations

• Offer non-invasive functional imaging (see Use of Non-invasive Functional Testing for Myocardial Ischaemia) for myocardial ischaemia if 64-slice (or above) CT coronary angiography has shown CAD of uncertain functional significance or is non-diagnostic 
• Offer invasive coronary angiography as a third-line investigation when the results of non-invasive functional imaging are inconclusive. 

Use of Non-invasive Functional Testing for Myocardial Ischaemia

• When offering non-invasive functional imaging for myocardial ischaemia use:
  • myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT), or
  • stress echocardiography, or
  • first-pass contrast-enhanced magnetic resonance (MR) perfusion, or
  • MR imaging for stress-induced wall motion abnormalities

Take account of locally available technology and expertise, the person and their preferences, and any contraindications (for example, disabilities, frailty, limited ability to exercise) when deciding on the imaging method.

• Use adenosine, dipyridamole, or dobutamine as stress agents for MPS with SPECT, and adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion 
• Use exercise or dobutamine for stress echocardiography or MR imaging for stress-induced wall motion abnormalities 
• Do not use MR coronary angiography for diagnosing stable angina 
• Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD. 

Making a Diagnosis Following Investigations

• Confirm a diagnosis of stable angina and follow the NICE guideline on stable angina when:
  • significant CAD (see Box 1) is found during invasive or 64-slice (or above) CT coronary angiography, or
  • reversible myocardial ischaemia is found during non-invasive functional imaging 
• Investigate other causes of chest pain when:
  • significant CAD (see Box 1) is not found during invasive coronary angiography or 64-slice (or above) CT coronary angiography, or
  • reversible myocardial ischaemia is not found during non-invasive functional imaging 
• Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries.