Chest pain assessment

Question 1

Immediate management of acute chest pain - suspected ACS

Answer 1

Immediate management of suspected acute coronary syndrome (ACS)
glyceryl trinitrate
aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
do not routinely give oxygen, only give if sats < 94%*
perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS

Question 2

Referral of chest pain

Answer 2

current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
chest pain 12-72 hours ago: refer to hospital the same-day for assessment
chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

Question 3

NICE AHGINAL PAIN definition

Answer 3

1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN in about 5 minutes
   patients with all 3 features have typical angina
   patients with 2 of the above features have atypical angina
   patients with 1 or none of the above features have non-anginal chest pain

Question 4

Stable angina cannot be excluded by clinical assessment alone- line of management

Answer 4

1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography

Question 5

Non-functional imaging

Answer 5

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