At-a-glance (what clinicians actually need)
- Rule out ACS first: ongoing pain, dynamic ECG changes, haemodynamic instability, syncope, or high-risk features → emergency pathway.
- Stable symptoms (possible angina): NICE CG95 supports a structured pathway; CT coronary angiography (CTCA) is typically first-line for stable chest pain investigation.
- Do not rely on “normal ECG” to dismiss significant coronary disease; use clinical risk + pathway.
- Always safety-net: explicit return/999 advice if pain recurs, becomes prolonged, or is associated with collapse/SOB/diaphoresis.
Red flags (send to ED / emergency services)
- Ongoing chest pain suspicious for ACS (especially >15–20 minutes, at rest, with autonomic symptoms).
- Associated high-risk features: syncope, severe breathlessness, hypotension, arrhythmia, or new neurological deficit.
- ECG concerns: ST elevation/depression, new T-wave inversion in a convincing presentation, new LBBB in high suspicion.
- Non-coronary emergencies: aortic dissection features (tearing pain/radiation, pulse deficit), PE features (pleuritic pain + hypoxia/haemoptysis), pneumothorax features, or oesophageal rupture red flags.
Stable chest pain investigation pathway (NICE CG95 — practical summary)
- Initial: careful history (typicality: constricting discomfort, precipitated by exertion/emotion, relieved by rest/GTN), risk factors, and basic exam. Do a 12-lead ECG.
- First-line test (stable symptoms): CT coronary angiography (CTCA) to assess coronary anatomy where available/appropriate.
- If CTCA is inconclusive or shows possible significant disease: functional imaging for ischaemia or invasive coronary angiography based on local pathway.
- Initial management while awaiting tests: treat risk (smoking cessation, BP/diabetes optimisation, statin per lipid pathway) and consider anti-anginal therapy per local formulary where clinically appropriate.
- Clear safety-net: “If pain occurs at rest, lasts >15 minutes, or is associated with collapse/severe SOB — call emergency services.”
Frequently asked questions
Does a normal ECG rule out angina or significant coronary disease?
No. A normal resting ECG does not exclude coronary disease. Use symptom pattern + pathway testing (often CTCA first-line for stable symptoms) and safety-net for acute features.
What is the key “stable chest pain” test in NICE CG95?
For stable chest pain of recent onset, NICE CG95 supports CT coronary angiography (CTCA) as a typical first-line investigation, with further testing guided by CTCA findings and local pathways.
What should I put in the RACPC referral?
Symptom typicality, exertional threshold, risk factors (smoking, diabetes, CKD), ECG findings, baseline meds, and whether symptoms are stable vs crescendo/at rest.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.