Signs and Symptoms

Query personal history of ischemic heart disease (IHD), acute myocardial infarction (AMI), coronary revascularisation or any other cardiovascular disease.

Symptoms, assess

• Conditions likely to precipitate pain
• Duration of symptoms (when did episodes of pain first start)
• Duration of pain (how long does each episode last)
• Exacerbating/ relieving factors
• Response to short acting nitrates, if any
• Family history of heart disease
• Co-morbidities (hypertension, hyperlipidaemia, diabetes)
• Smoking history

Examination:

• Heart rate, rhythm, heart sounds, murmur
• Chest examination
• Blood pressure
• BMI

Anginal pain is:

• Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms
• Precipitated by physical exertion
• Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes

Symptoms that make coronary disease unlikely are:

• Unrelated to activity
• Brought on by inspiration
• Accompanied by difficulty in swallowing

Differential Diagnoses

• Gastro-oesophageal reflux disease
• Musculoskeletal pain
• Pleuritic or infective pain

• Pain at rest with a history suggestive of infarction, especially if pain persists for longer than 15 minutes
• Pain with haemodynamic instability

The presence of any of these findings should prompt the clinician to consider acute admission

Bloods:

• Full blood count
• Renal
• Lipids
• HbA1c
• Liver function test
• Thyroid function test

Electrocardiogram (ECG) is mandatory (but can be normal in up to 90% of patients with typical angina)

Chest x-ray if relevant signs or symptoms

If you suspect pain of cardiac origin, consider starting the following medication where appropriate and safe to do so:

• Aspirin
• Beta-blocker (calcium channel blocker if beta-blocker contraindicated)
• Statin
• Sublingual nitrate
• Lifestyle advice

For men older than 70 with atypical or typical symptoms, assume an over 90% likelihood of coronary disease

For women older than 70, assume an estimate of 61 – 90% except women at high risk and with typical symptoms where a risk of above 90% should be assumed

High risk = smoking, diabetes and cholesterol above 6.5

Low risk = none of these

ECG changes increase likelihood of coronary artery disease

Referral Criteria

• If recent onset (within the last 3 months) refer to Rapid Access Chest Pain Clinic:
  • A resting ECG and blood results are mandatory for this clinic

Rapid Access Chest Pain Clinic Referral form

• If onset longer than 3 months, refer routinely to cardiology
• Patients with a Coronary Artery Disease (CAD) risk less than 10% should have other causes of chest pain considered first and not be referred to RACPC
• Patients with a CAD risk of 90% or more should be managed as stable angina and a referral may not be necessary
• Other patients with a clinical suspicion of exertional angina should be referred

Referral Instructions

For Rapid Access Chest Pain Clinic:

e-Referral Service Selection

• Specialty: Cardiology
• Clinic Type: Rapid Access Chest Pain Clinic - Urgent
• Service: DRSS-Northern-Cardiology- Devon ICB- 15N

For Cardiology:

e-Referral Service Selection

• Specialty: Cardiology
• Clinic Type: Not Otherwise Specified
• Service: DRSS-Northern-Cardiology- Devon ICB- 15N

Referral Form

Rapid Access Chest Pain Clinic Referral form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: December 2015