Systematic Approach

A logical and systematic approach to these patients will achieve a diagnosis in the vast majority of cases whilst they are in the ED (see algorithm in Figure 1). A focused history, with the use of evidence based risk stratification and physical examination supported by an ECG and CXR in most, with some specific ancillary investigations in a few, will allow a firm diagnosis to be made or confident reassurance to be given. All of the assessments and investigations discussed in this module are within the remit of the emergency physician and should be available within the ED.

This module is about achieving a diagnosis in a patient presenting with chest pain, not about the treatment of a condition once a diagnosis has been made. Once a diagnosis has been reached with the required degree of certainty, management of that condition is covered in the relevant module within RCEMLearning and the patient “drops” out of the algorithm.

Note – According to Chest Pain NICE guideline 95, anginal pain is (1) a ‘constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms’ that is (2) precipitated by physical exertion, and (3) relieved by rest or GTN within 5 minutes.

NICE defines chest pain as being “atypical” if only two of these three features are present, or “non-anginal” if one or none of these exist.⁽³⁾

The European Society of Cardiology describes ‘atypical presentations’ of MI include epigastric pain, indigestion-like symptoms and isolated dyspnoea.⁽⁴⁾