Cardiac chest pain: identification, referral and management in primary care

Cardiac chest discomfort can be caused by valvular disease, such as moderate to severe aortic stenosis, spontaneous coronary artery dissection (SCAD), pericarditis, myocarditis and aortic dissection, but most commonly is caused by coronary artery disease (CAD) restricting blood flow to the myocardium, thus myocardial ischaemia^​1​.

Myocardial ischaemia is often described as ischaemic heart disease (IHD). Cardiac chest discomfort can be a red flag for a cardiac issue, particularly in acute presentations. Between 5% and 14% of individuals diagnosed with acute coronary syndrome (ACS) die within the year following their diagnosis, with approximately half of these fatalities occurring within the first four weeks^​2​. In 2022, IHD was the leading cause of male mortality, accounting for 13.3% of male deaths in England and Wales^​3​. The leading cause of death in females in England and Wales was dementia, with IHD, which ranked second, accounting for 7.2% of all deaths^​3​. In comparison, malignancy in both genders ranks lower — 5.1% and 4.8%, respectively — despite the high public profile of cancer^​3​.

The word ischaemia derives from the Greek word ‘iskhaimos’, which means ‘stopping blood’^​4​. Coronary ischaemia can result in angina, which usually manifests as chest pain and is often described as a discomfort, heaviness, tightness or pressure^​5​. Angina is a symptom of myocardial ischaemia but is not a disease itself.

The focus of this article will be identification of myocardial ischaemia caused by coronary artery disease. It will demonstrate how pharmacists and other healthcare professionals in primary care can determine whether discomfort is non-cardiac, outline the red flags to look out for and summarise recommended referral pathways and management. 

Stages of myocardial ischaemia

There are broadly two stages of myocardial ischaemia presentations: stable angina^​6​ and acute coronary syndrome (ACS)^​7​, which includes unstable angina and certain classifications of myocardial infarction. 

Stable angina is predictable chest pain typically triggered by exertion or stress and relieved by rest. Acute coronary syndrome (ACS) is a spectrum of conditions, including unstable angina, which is unpredictable and may occur at rest or with minimal exertion, and often signifies a more severe underlying issue.

A patient may present to primary care at any of these stages but commonly there are warning signs of a heart attack. The majority of patients show initial signs of stable angina, which will reduce the chance of advancing to more serious presentations of myocardial ischaemia, if they are identified and managed early.

Figure 1 shows the risk factors associated with coronary plaque formation and the associated physiological changes. When the plaque impairs blood flow, the presentation can move from stable angina to myocardial infarction, and is often caused by plaque rupture^​8​.

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Atypical cardiac chest pain phenomena

There are other conditions that can also cause chest pain and these have different diagnostic characteristics. The symptoms associated with coronary artery spasm (Prinzmetal angina), spontaneous coronary artery dissection (SCAD) and severe valve disease can all present with chest pain or discomfort. All three result from a reduction in myocardial blood flow but the mechanisms vary. While coronary artery spasm and SCAD are characterised by temporary, often unpredictable chest pain (resulting from artery constriction or dissection), severe valve disease may cause symptoms such as chest pain, shortness of breath and fatigue, owing to the heart’s impaired ability to pump blood effectively. 

Coronary artery spasm is more common in women and more prevalent with recreational drug use, particularly cocaine^​9​. The pain of a coronary artery spasm is often more acute than that of exertional angina. SCAD is more common in menstruating women and often presents as a myocardial infarction, accounting for 25% of all heart attacks in women aged under 50 years^​10​.

The symptoms associated with valve disease most closely mimic exertional angina. The disease of the aortic valve in particular limits the flow of blood from the ventricle through the aortic valve. Aortic stenosis results in the heart having to work harder to open the valve so the muscle grows in size, increasing demand on the arteries, which are in turn underfilled because of reduced flow past the aortic valve. This obviously makes exertion more problematic. Left untreated, this condition can cause irreversible heart damage, ultimately resulting in heart failure. 

It is beyond the scope of this article to explore these presentations further, but it is well described in the literature^{​11–13​}. Practitioners should be aware of these conditions; however, they are often challenging to diagnose in primary care settings owing to their complexity. Initial identification may be possible through basic questioning about chest pain, but definitive diagnosis usually requires further specialised testing and evaluation. 

Assessment for typical angina

Diagnosing angina based solely on symptom history can be challenging so careful questioning is crucial. The likelihood of angina should be assessed in the context of the patient’s risk factors (see Figure 1) and overall probability of developing cardiovascular disease.

The QRISK3 score, which is commonly used in primary care and listed in the British National Formulary, is aimed to help evaluate this risk^​14​. National Institute for Health and Care Excellence (NICE) guidance on assessment for chest pain suggests criteria for the determination that a chest pain is angina^​15​. This has been adapted in all the South West London rapid access chest pain clinics (RACPCs). If there are less than two features listed below, then the referrer is advised that the referral is inappropriate:

1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arm;  
2. Precipitated by physical exertion;
3. Relieved by rest or administration of glyceryl trinitrate (GTN) in approximately five minutes. 

It is noteworthy that those with myocardial ischaemic symptoms (angina) will often deny chest “pain” and instead use any word but this. The term discomfort in this tool is used advisedly. 

Location and assessment of discomfort

The description of angina pain or discomfort can vary but its location rarely does. See Figure 2 for the common sites.

In the assessment of discomfort a useful and popular tool is using the mnemonic SOCRATES^​16​. This refers to Site, Onset, Character, Radiation, Alleviation, Time, Exacerbation and Severity. This will help the practitioner to employ a methodical approach to chest pain assessment. 

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• Site (position) — The first tool to help you differentiate cardiac chest discomfort is the variation in location. Unilateral left sided presentation is common but unilateral right sided presentation is highly unlikely to be cardiac^​17​. The sole presence of left sided chest discomfort is highly predictive of anginal chest pain. Anginal chest discomfort may present bilaterally or centrally or the discomfort may be in the upper back, again central or across the whole region or left scapula;
• Onset — This typically occurs with exertion, usually gradual onset;
• Character — This is usually described as heavy, crushing, tight, constricting, less often burning. More commonly females describe indigestion-type symptoms so be wary of this^​18​;
• Radiation — This may radiate to the left side or down both sides or to jaw or lower teeth. A patient may only present with pain in the tooth or left arm and only on exertion;
• Associated factors — Angina can be associated with breathlessness, sweating or belching;
• Timing/duration — Discomfort relieved by rest within 5–15 minutes. If longer, suspect either a worsening of angina or alternate cause of chest discomfort. Constant pain is a sign the problem is not angina;
• Exacerbating factors — This is provoked by exertion and worsened by continuing same level of exertion;
• Severity — This is usually a discomfort at the stable stage. Not a pain, it is mild, not troubling. As it is mild, it is regularly missed and presents late. More advanced disease results in more severe pain. Those suffering a myocardial infarction will often describe very strong debilitating pain, which they can describe as “the worst pain ever”.

Other signs that the patient’s chest pain is not angina include:

• Pain worse on inspiration;
• Pain worse on palpation;
• Pain relieved or provoked by movement of upper body;
• Pain on eating.

The following case study provides an opportunity to apply these assessment principles to a patient scenario.

In cases where the initial assessment suggests the patient may be experiencing cardiac chest pain, an ECG and a troponin I assay will be performed. These tests are crucial for confirming the diagnosis and determining the underlying cause of the symptoms, which will help guide the subsequent management plan. These diagnostic tools allow us to categorise the presentation as either ST or non-ST elevation MI^​22​. ST elevation refers to a sign on the ECG whereas the troponin I assay will indicate myocardial cell death. Unstable angina typically refers to patients who experience concerning symptoms but do not have elevated troponin levels. Despite the absence of elevated troponin, unstable angina is associated with a risk of non-fatal heart attacks comparable to that of patients with confirmed myocardial infarction^​23​. For more on ECG interpretation, see the article ‘Interpretation of electrocardiograms‘.

NICE recommends immediate coronary intervention (revascularisation) for those with ongoing symptoms^​24​. In the case study above, Mr A’s symptoms resolved quickly but intervention is still recommended. The timing of these interventions should be determined by the risk of future events or mortality^​24​. For more detail, see NICE guidance on the management of ACS and recent onset chest pain^​24,25​. 

Again using the example of Mr A from the case study, we are able to show how the ‘SOCRATES’ method provides an opportunity to work through the main differentials of cardiac chest pain and rule out a number of other cardiac conditions (see Table)^{​26–28​}.

Red flags

If any of the following are suspected, emergency care should be provided including a 999 call: 

• Aortic dissection;
• Myocardial infarction;
• Haemodynamic compromise is present (symptoms include cool clammy peripheries, rapid breath, reduced blood pressure and loss of pallor).

Non cardiac causes of chest pain

While the focus of this article is on identification of cardiac causes of chest pain, it is also helpful to briefly consider non-cardiac causes. Being able to rule these out enables the practitioner to have more confidence in a cardiac diagnosis. 

Gastrointestinal causes 

Gastro-oesophageal reflux disorder (GORD) is a very common cause of chest pain. Other characteristics and features include: bad breath, bad taste in mouth, stomach pain, trouble swallowing and vomiting. For more information on GORD, see the article ‘Case-based learning: GORD in adults’.

Gallbladder disease (cholecystitis) can also cause chest pain^​29​. Characteristics include pain localised to right upper abdomen, as well as pain that radiates to the back chest and shoulder that is worse after a heavy meal.

Respiratory causes 

Pulmonary embolus also causes chest pain^​30​. It is often associated with breathlessness and hypoxia or cyanosis, may have haemoptysis, feeling lightheaded, sweating, shortness of breath, leg pain or leg swollen on one side and inspirational chest pain. The likelihood of pulmonary embolus is increased with recent periods of inactivity, such as long-distance travel.

Chest pain is also a symptoms of chest infection/pneumonia. Presentation is similar to pulmonary embolus but without unilateral leg swelling. Other symptoms include fever, sputum that appears infected, rapid shallow breathing and confusion (in older people).

Muscular skeletal causes 

• Costochondritis — Inflammation of the costochondrial muscles. This is typified by discomfort on palpation. It is continuously present on provocation of pressing and inspiration;
• Trauma or degenerative changes — History present of mechanical trauma or discomfort on movement or pressing. Imaging may be needed^​31​.

Assessment and management of suspected cardiac ischaemia in primary care settings

Once the practitioner suspects that the discomfort could be myocardial ischaemia, the management of cardiac chest pain in the community is limited by the resources available. When a patient presents with chest discomfort there are two important things that can help with the decision-making as to appropriate next steps: careful questioning and establishing the vital signs. The immediate priority is to determine whether the patient needs emergency help. Below is a list of red flags that will assist with this^​24​. 

Obtain a brief relevant medical history, (including cardiac history and symptoms history) and consider the likelihood of disease based on cardiovascular risk factors and tools, such as QRISK score. If possible, obtain a full set of vital signs (e.g. blood pressure, oxygen levels, heart rate, ECG).

The ‘Look, Listen, Feel’ approach to physical assessment can also provide valuable information:

LOOK — How does the patient look?

Colour, pallor, breathlessness, rapid breathing, clutching chest. Use your tools for signs of haemodynamic compromise (considering the patients norm if available). 

LISTEN — What does the patient say?

Careful questioning, history taking. Use SOCRATES to establish risk especially onset, timing and severity. Make sure you cover all points and think about your differential diagnoses, use your red flags (below) to determine urgency. What is the likelihood and is there a history of angina?

FEEL — Is the patient clammy, cool or warm? 

For more on physical assessment approaches see: ‘Introduction to clinical assessment for prescribers’.

Figure 3 provides a summary of action to take depending on the nature of symptoms. 

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Safety netting advice

If the assessment concludes that non-urgent assessment is required, it is important to provide the patient with clear safety netting advice. Make sure that they understand what red flags to look for and what action to take if their condition or symptoms change.

For more information on safety netting and red flag symptoms see: 

• ‘How to provide patients with safety-netting advice’;
• ‘How to identify red-flag symptoms and refer patients appropriately‘.

Summary

Effective assessment and early intervention are key when responding to cardiac chest pain and the steps practitioners should take can be easily memorised using the mnemonic SPURS: 

• SOCRATES assessment (to gather history of symptoms and work through key differentials)
• Physical assessment and vital signs (assess haemodynamic status)
• Urgency (establish if red flags are present)
• Risk factors (estimate likelihood of disease)
• Signpost appropriately (using Figure 3 as a guide).