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Chest Pain evaluation for the General Practitioner – Part 1

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Chest Pain evaluation for the General Practitioner – Part 1

Author: Prof Rohan Jayasinghe

Case Vignette:


A 59 year-old female presents to you with 30 minutes of epigastric tightness, associated with nausea. She has the coronary risk factors of obesity, smoking and hypertension.


Myocardial ischaemia and myocardial Infarction should be differentiated from non-ischaemic chest pain.

Other diagnoses of concern include; acute pericarditis, aortic dissection, pulmonary embolism, and pneumothorax

Be alert to the possible atypical nature of the female patient presenting with coronary ischaemia

Causes of acute chest discomfort:
  • Acute myocardial infarction (AMI)
  • Angina
  • Pericarditis
  • Coronary spasm
  • Myocardial bridging
Potentially life-threatening emergencies:
  • AMI
  • Pericarditis
  • Dissection of the aorta
  • Pulmonary embolism
  • Pneumothorax
Non-emergency, but potentially serious causes:
  • Unstable angina
  • Pneumonia
  • Pleurisy
Other causes of chest pain:
  • Oesophagitis
  • Oesophageal spasm
  • Oesophageal tear / Mallory Wise tear
  • Costochondritis
  • Muskulo-skeletal injury / inflammation
  • Fibromyalgia / polymyalgia
  • Fractured ribs
Salient features of acute myocardial infarction
  • Duration of the pain is more than 20  mins
  • The location of the pain is Retrosternal – with radiation up the neck, to the left shoulder or down the left arm (sometimes down both arms)
  • The pain is described as “Squeezing, pressing, heaviness, with no pleuritic features (not worsened with respiration)
  • Associated Nausea, vomiting. These features are seen especially with inferoposterior wall ischaemia
  • Altered haemodynamics; Bradycardia, hypotension – are very concerning developments
  • Dyspnoea and desaturation – may suggest evolving pulmonary oedema

It is important to note that classic features of chest pain described above may be absent in female patients with acute coronary ischaemia. Females often present with atypical symptoms. Hence there is often delayed recognition of the clinical significance of symptoms in females leading to more harm and higher mortality.

  1. It is important to distinguish cardiac chest pain from non-cardiac chest pain
  2. Once recognised cardiac pain should be classified as stable angina (that is triggered by exercise, heightened emotions, sexual intercourse, heavy meal etc.), possible acute coronary syndrome or definite acute coronary syndrome
  3. If you consider definite acute coronary syndrome you should determine if the patient would benefit from acute reperfusion therapy (primary angioplasty or thrombolysis)
  4. Check the ECG for any ST segment elevation, ST segment depression or T wave inversion
  5. If above changes are observed on ECG call an ambulance / order urgent cardiac biomarkers (troponin) / plan to dispatch the patient to the nearest emergency department / keep the patient stable / maintain vital signs; pulse rate, blood pressure, oxygen saturations
  6. Administer aspirin 300 mg,
  7. If the diagnosis is stable angina – refer the patient for exercise stress echocardiography and cardiology consultation
  8. Patients with chest pain, hypertension, hypotension, dyspnoea, palpitations, syncope, past history of cardiac disease should have a resting trans-thoracic echo study to define cardiac anatomy and function.