assessment of stable chest pain of suspected cardiac origin
Last reviewed 12/2020
Presentation with stable chest pain
- stable angina should be diagnosed based on one of the following:
- clinical assessment alone or
- clinical assessment plus diagnostic testing (that is, anatomical testing
for obstructive coronary artery disease [CAD] and/or functional testing
for myocardial ischaemia)
- if people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see tables), further diagnostic investigation is unnecessary. Manage as angina
Table 1: Non-anginal chest pain - % likelihood of CAD
| Men | Men | Women | Women | |
| Age (years) | Lo | Hi | Lo | Hi |
| 35 | 3% | 35% | 1% | 19% |
| 45 | 9% | 47% | 2% | 22% |
| 55 | 23% | 59% | 4% | 45% |
| 65 | 49% | 69% | 9% | 49% |
Table 1 represents people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely
Table 2: Atypical anginal pain - % likelihood of CAD
| Men | Men | Women | Women | |
| Age (years) | Lo | Hi | Lo | Hi |
| 35 | 8% | 59% | 2% | 39% |
| 45 | 21% | 70% | 5% | 43% |
| 55 | 45% | 79% | 10% | 47% |
| 65 | 71% | 86% | 20% | 51% |
Table 3: Typical angina - % likelihood of CAD
| Men | Men | Women | Women | |
| Age (years) | Lo | Hi | Lo | Hi |
| 35 | 30% | 88% | 10% | 78% |
| 45 | 51% | 92% | 20% | 79% |
| 55 | 80% | 95% | 38% | 82% |
| 65 | 93% | 97% | 56% | 84% |
- for men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
- For women older than 70, assume an estimate of 61-90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed
- Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD)
- Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre)
- Lo = Low risk = none of these three
- Note:
- These results are likely to overestimate CAD in primary care populations. If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.
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
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. Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain)
Reference: