10 steps before you refer for chest pain

March 2009    Volume 16, Issue 2   Br J Cardiol 2009;16:80-84

Authors:
Sudhakar Allamsetty, Sreekala Seepana, Kathryn E Griffith

Chest pain is a common presentation in general practice. Each year about 1% of the UK population visit their GP with chest pain.1 The average GP will see, on average, four new cases of angina each year.2 The Euro heart survey of newly diagnosed stable angina patients showed that the incidence of death and myocardial infarction (MI) was 2.3/100 patient-years. This is increased in patients with a previous MI, short history, more severe symptoms and with heart failure or other co-morbidities, such as diabetes.3 The recognition of these patients as at high risk for cardiovascular events has led to the improvement of diagnosis and management of angina. Rapid access chest pain clinics have been developed to allow quick assessment of patients with new onset angina as part of a National Service Framework for coronary artery disease.

1. Take a detailed history

A careful history remains the cornerstone of the diagnosis of angina pectoris.⁴ There are some typical characteristics of chest pain that increase the likelihood that the pain is angina and caused by underlying coronary heart disease (CHD).⁵

Stable angina is characterised by the type of discomfort and location (table 1):⁶ it is elicited by physical exertion or emotion and relieved by rest or glyceryl trinitrate (GTN). Duration is short and it is worse in cold weather or after a meal (table 2).

In unstable angina, the symptoms are more severe, more prolonged, more frequent, and may occur at lower thresholds or even at rest. Patients who are considered to have unstable angina should be admitted to hospital acutely, and their management is not included here.

2. Consider non-cardiac causes of chest pain

The most common causes of chest pain seen in the GP surgery are non-cardiac (table 3). They are usually differentiated by careful history taking. Differential diagnoses include oesophageal disorders, such as gastro-oesophageal reflux or oesophageal dysmotility suggested by the character of the pain with epigastric burning, acid reflux, and relief with antacids.

Pleural pain may be caused by infection, pulmonary embolism or tumour. The character of the pain is important with elucidation of pulmonary symptoms. Musculoskeletal pain, such as with Tietz syndrome, is suggested by apleuritic character and local tenderness. Referred pain from the thoracic spine can be suggested by previous history, trauma and local tenderness. Biliary pain with epigastric or right hypochondrial discomfort, is worse with fatty foods and associated with nausea.

Psychological causes include anxiety, panic attacks, and depression. Somatic symptoms of psychological disorders are very common, however, it is also important to remember that the onset of angina itself may induce significant anxiety.

Anginal pain is not usually sharp or stabbing in nature, it is not usually influenced by respiration, it is not fleeting nor does it last all day. Scottish Intercollegiate Guidelines Network (SIGN) guidelines⁵recommend that if the diagnosis is uncertain then practitioners should not give the impression that the patient has angina, which may lead to the development of adverse false beliefs. Early specialist opinion through Rapid Access Chest Pain Clinic may help to dispute an inaccurate diagnosis and reduce the risk of these false beliefs developing.

Low-risk patients with atypical symptoms should be managed in primary care where possible.⁵ It is important to explain symptoms and concerns, and provide reassurance where necessary. Correct management by a confident GP may both reduce morbidity and the need for referral.

3. Establish the risk factors: how likely is it that your patient has CHD?

Risk factors can be modifiable or non-modifiable. Non-modifiable risk factors include increasing age and sex. About 85% of people who die of coronary artery disease are aged 65 years or older.⁷ Men have a greater risk of premature heart disease than women.⁷

The risk of cardiovascular disease is higher in ethnic groups such as South Asians, and those of African-Caribbean origin. This increased risk is partly due to higher rates of high blood pressure, obesity and diabetes in these populations. Risk of cardiovascular disease increases if there is a positive family history of premature cardiovascular disease in a first-degree relative. This is defined as a history of premature CHD under age 55 in fathers, sons or brothers, or under age 65 in mothers, daughters or sisters.⁸

Modifiable risk factors include smoking, which is the most important preventable risk factor for cardiovascular disease and stroke. Increase in weight and lack of physical exercise contribute to cardiovascular risk, partially related to association with type 2 diabetes. Diabetes mellitus is considered by some to be a cardiovascular disease equivalent.

High total cholesterol and low-density lipoprotein (LDL) cholesterol with low high-density lipoprotein (HDL) cholesterol are modifiable risk factors. High salt consumption and a diet rich in saturated fat can contribute to cardiovascular disease. Elevated blood pressure is associated with increased heart attack and strokes. Excess alcohol consumption can lead to increased blood pressure, heart failure and stroke.

4. Perform a physical examination

This is an important step⁹ before referral (table 4) because it may identify conditions that can precipitate angina (such as anaemia or hyperthyroidism) and conditions other than CHD that can present with angina (aortic stenosis/hypertrophic obstructive cardiomyopathy). There may also be findings that would make a treadmill test unsuitable, such as uncontrolled blood pressure or aortic stenosis.

A comprehensive examination should include weight and height to allow calculation of body mass index, and waist circumference to evaluate presence of the metabolic syndrome. Record the pulse rate, rhythm and blood pressure. Listen for the presence of murmurs, especially aortic stenosis. Look for evidence of hyperlipidaemia with xanthelasma or tendon xanthomata. Examine for evidence of peripheral vascular disease with absent foot pulses, bruits, skin changes or hair loss. Look for evidence of anaemia or thyroid disease.

5. Carry out the relevant investigation

Where there is a low index of suspicion of CHD, then it is not recommended that the patient undergoes further tests.^9,10

For patients considered at higher risk, the following tests are recommended. A full blood count, serum creatinine or estimated glomerular filtration rate (eGFR), a fasting lipid profile and blood glucose. Thyroid function tests should be carried out if there is clinical suspicion of thyroid disease.

A resting 12-lead electrocardiogram (ECG) should be recorded in anyone with suspected angina to provide information on rate and heart rhythm to check for atrial fibrillation or heart block, and to check for signs of myocardial ischaemia, hypertrophy, or previous MI. Some ECG abnormalities may exclude patients from a diagnostic treadmill test such as left bundle branch block (LBBB) and atrial fibrillation. A normal ECG does not exclude angina as more than 50% of people with stable angina have a normal resting ECG.¹¹

Chest X-ray is not useful in the initial evaluation of chest pain, unless there is a history suggestive of heart failure, pulmonary disease or valvular pathology.

6. Estimate the cardiovascular disease risk

Using the information obtained by the recommended assessment, all patients should have their risk of cardiovascular disease estimated using a risk estimation tool. At present the Joint British Societies (JBS2) risk estimation tool¹² is recommended and the ASSIGN tool in Scotland.

The use of these charts is not appropriate for patients with pre-existing cardiovascular disease, chronic kidney disease and proteinuria, familial hypercholesterolaemia or other inherited dyslipidaemia, or type 1 and type 2 diabetes mellitus, for whom the UK Prospective Diabetes Study (UKPDS) risk assessment tool may be used.

Cardiovascular risk is higher than indicated in the charts for those with a family history of premature cardiovascular disease or stroke (male first-degree relatives aged <55 years and female first-degree relatives aged <65 years), which increases the risk by a factor of 1.5,⁸ and 2.0 times with two first-degree relatives. It is also higher in those of South Asian background where the increased risk for men is 1.4 times, in the presence of left ventricular hypertrophy (LVH) on the ECG, and in those with raised triglyceride levels. Special consideration is required for those with chronic kidney disease without proteinuria, where a correction factor is not yet identified, women with premature menopause and those who are not yet diabetic, but have an impaired fasting glucose.

7. Give lifestyle advice

Anyone with angina should be advised to stop smoking. Smoking increases the risk of small vessel disease and the risk of dying from it, and risk is increased as more cigarettes are smoked.¹⁰ Risk of a cardiovascular event falls from the first day the patient stops. Patients may need referral to specialist smoking cessation services and nicotine replacement therapy.

The Mediterranean diet is recommended with five portions of fruit and vegetables, and monounsaturated fats from olive and rapeseed oils. People at high risk of cardiovascular disease are recommended to consume at least two portions of fish per week, including one portion of oily fish. Omega-3 fatty acids are also found in flaxseed, almonds and walnuts.

Weight loss is recommended for all those who are obese or overweight. Moderate exercise for 30 minutes a day, on most days, within the limits set by their symptoms, should be advised.¹⁰ Patients with cardiovascular disease will be offered a screening questionnaire for anxiety and depression, and may need advice to manage stress, relaxation techniques and setting realistic goals.

Holders of Large Goods Vehicle (LGV) and Passenger Carrying Vehicle (PCV) licences with new onset of angina should notify the Driver and Vehicle Licensing Agency (DVLA) and stop driving their vehicle. Holders of an ordinary driving licence may still drive providing that symptoms are controlled, but must inform their motor vehicle insurance company. People who operate heavy machinery may also be affected.¹³

It is important to reassure that angina does not damage the heart, however, patients should be advised about the risk and symptoms of heart attack and when to call 999.¹⁰

8. Treatment to control symptoms and reduce cardiovascular risk

There are two arms to treatment, which should be commenced if there is a high suspicion of cardiovascular disease.

Sublingual GTN should be prescribed to abort attacks, or to provide a short period of prophylaxis while doing activities likely to precipitate angina. If angina is not relieved by GTN treatment they should be advised to seek urgent medical advice.

A beta blocker should be commenced as first-line treatment for long-term symptom control.

A calcium channel blocker, diltiazem, is usually the first choice where a beta blocker is either contraindicated or not tolerated.

Aspirin 75 mg should be started if cardiovascular risk >20%, or if there is a high suspicion of CHD and blood pressure <150/90 mmHg. If there is a high risk of gastrointestinal adverse effects it can be used in combination with a proton-pump inhibitor. Clopidogrel 75 mg is an alternative option.

Statins should be offered depending on the cardiovascular risk for primary prevention and for all patients who fit into secondary prevention. It is recommended to start with simvastatin 40 mg.⁸

9. Consider a Rapid Access Chest Pain Clinic referral

These clinics offer open-access referral for patients with new onset of chest pain and patients should be seen within two weeks. They may be nurse- or technician-led, and usually involve the patient having an exercise ECG, providing valuable prognostic information.

People should not be referred for an exercise ECG if they are on maximal medical treatment and still have symptoms, the diagnosis of CHD is unlikely, or if they are physically incapable of taking the test. Patients who may have aortic stenosis or cardiomyopathy are not suitable. There is no point in referring patients in whom the results of an exercise ECG would not affect management¹⁰ or who do not wish further investigation of their pain.

The management of patients with chest pain from referral to definitive treatment, including bypass surgery, is now included within an 18-week ‘commissioning pathway’. During this time, patients will be subjected to a multitude of investigations and treatments. The primary-care team has a key role in supporting the patient and should be closely involved in education and lifestyle changes to promote the best possible outcome.

10. Consider referral to a cardiologist

Not all patients should be referred, and some may not wish further investigation, however, those in the following groups should be considered for early referral to a cardiologist. This would include people with new onset of chest pain, who have had a previous MI, coronary artery bypass grafting, or percutaneous transluminal coronary angioplasty; also people who seem to have ECG evidence of a previous MI, or other significant abnormality; people who fail to respond to medical treatment; and people who have an ejection systolic murmur suggesting aortic stenosis.

Some people with the following symptoms may have an acute coronary syndrome and should be considered for hospital admission. They include those with a pain on minimal exertion, pain at rest (which may occur at night), and those in whom angina seems to be progressing rapidly despite increasing medical treatment. Evidence of an MI in the ECG or dynamic changes suggestive of ischaemia should be urgently transferred to hospital.

Conflict of interest

None declared.

References

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7. British Heart Foundation Statistics Website. www.heartstats.org
8. National Institute for Health and Clinical Excellence. CG67 Lipid modification: NICE guideline. London: NICE, 2008.
9. CKS Library. www.ckslibrary.nhs.uk
10. Department of Health. 18 week commissioning pathway – chest pain; supplementary information version 1.2. London: DoH, July 2007.
11. Snow V, Barry P, Fihn SD et al. Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians. Ann Intern Med 2004;141:57–64.
12. British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, Stroke Association. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(Suppl 5):v1–v52.
13. Driver and Vehicle Licensing Agency. www.dvla.gov.uk

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