initial assessment and referral to hospital of possible acute chest pain of cardiac origin

Last reviewed 12/2020

Initial assessment and referral to hospital

• check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours
  
  
• determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering:
  • the history of the chest pain
  • the presence of cardiovascular risk factors
  • history of ischaemic heart disease and any previous treatment
  • previous investigations for chest pain
    
    
• initially assess people for any of the following symptoms, which may indicate an ACS:
  
  
  • pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
  • chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
  • chest pain associated with haemodynamic instability
  • new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes
    
    
• do not use people's response to glyceryl trinitrate (GTN) to make a diagnosis
• do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant feature
• do not assess symptoms of an ACS differently in ethnic groups. There are no major differences in symptoms of an ACS among different ethnic groups
  
  
• refer people to hospital as an emergency if an ACS is suspected and:
  • they currently have chest pain or
  • they are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead ECG is abnormal or not available
• if an ACS is suspected and there are no reasons for emergency referral, refer people for urgent same-day assessment if:
  • they had chest pain in the last 12 hours, but are now pain free with a normal resting 12-lead ECG or
  • the last episode of pain was 12-72 hours ago
    
    
• refer people for assessment in hospital if an ACS is suspected and:
  • the pain has resolved and
  • there are signs of complications such as pulmonary oedema. Use clinical judgement to decide whether referral should be as an emergency or urgent same-day assessment
    
    
• if a recent ACS is suspected in people whose last episode of chest pain was more than 72 hours ago and who have no complications such as pulmonary oedema:
  • carry out a detailed clinical assessment
  • confirm the diagnosis by resting 12-lead ECG and blood troponin level
  • take into account the length of time since the suspected ACS when interpreting the troponin level. Use clinical judgement to decide whether referral is necessary and how urgent this should be
    
    
• refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain
  
  
• when an ACS is suspected, start management immediately in the order appropriate to the circumstances and take a resting 12-lead ECG Take the ECG as soon as possible, but do not delay transfer to hospital
  
  
• if an ACS is not suspected, consider other causes of the chest pain, some of which may be life-threatening

Reference:

• 1) NICE (March 2010). Chest pain of recent onset.