GPAtlas🧭 When to suspect
Chest pain is one of the most common reasons for urgent primary-care contact, and it spans a vast differential – from benign musculoskeletal or oesophageal pain to immediately life-threatening acute coronary syndrome (ACS), pulmonary embolism (PE) and aortic dissection. The first task is not to reach a precise diagnosis but to decide, quickly, who needs emergency admission and who can be assessed in slower time.
Two features dominate that decision: the timing of the pain (is it present now, and did it start within the last 12 hours?) and the 12-lead ECG. Suspect ACS with central, heavy or crushing pain that radiates to the arm(s) or jaw, occurs at rest or on minimal exertion, and carries autonomic features (sweating, nausea, breathlessness). Suspect stable angina when pain is predictably brought on by exertion and relieved within minutes by rest or GTN. Crucially, do not use the response to GTN to decide whether pain is cardiac – it relieves oesophageal spasm too.
| Pain pattern | Most suggestive cause |
|---|---|
| Central, heavy or crushing; radiates to arm(s)/jaw; at rest or minimal exertion; sweating, nausea, breathlessness | Acute coronary syndrome |
| Predictable and exertional; relieved within minutes by rest or GTN | Stable angina |
| Sudden, severe, tearing; radiates through to the back; may have unequal arm blood pressures | Aortic dissection |
| Sudden and pleuritic; with breathlessness or tachycardia; VTE risk factors | Pulmonary embolism |
| Sharp, pleuritic and positional; eased by sitting forward | Pericarditis |
| Reproduced by palpation or movement; localised | Musculoskeletal |
| Burning, postprandial; acid taste or regurgitation; eased by antacids | Gastro-oesophageal reflux |
|
🧠 Clinical pearl The classic pattern can be absent. Older people, women and people with diabetes may have a myocardial infarction with little or no chest pain – breathlessness, fatigue, nausea, sweating or simple collapse may be the only clue. Keep the threshold for an ECG low in these groups, because the "textbook" history that triggers admission may never appear. |
Source: NICE CG95 · NICE NG185
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