How should I manage a patient with chronic chest pain who has a normal initial cardiac assessment?

When managing a patient with chronic chest pain who has had a normal initial cardiac assessment, the focus shifts to a detailed reassessment to determine if the pain is likely cardiac or due to other causes ¹.

• Clinical Assessment: You should take a detailed clinical history, documenting the patient's age and sex, the characteristics of the pain (location, radiation, severity, duration, frequency, provoking and relieving factors), any associated symptoms like breathlessness, and any history of angina, myocardial infarction (MI), coronary revascularisation, other cardiovascular disease, or cardiovascular risk factors ¹. A physical examination should be carried out to identify cardiovascular risk factors, signs of other cardiovascular disease, non-coronary causes of angina (e.g., severe aortic stenosis, cardiomyopathy), and to exclude other causes of chest pain ¹.
• Assessing Pain Typicality: Assess the typicality of the chest pain ¹. Anginal pain is defined as constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms, precipitated by physical exertion, and relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes ¹. The presence of three of these features indicates typical angina, two indicates atypical angina, and one or none indicates non-anginal chest pain ¹. Factors that make a diagnosis of stable angina more likely include age, male sex, and cardiovascular risk factors such as a history of smoking, diabetes, hypertension, dyslipidaemia, family history of premature coronary artery disease (CAD), or other established cardiovascular disease ¹. Features that make stable angina unlikely include continuous or very prolonged pain, pain unrelated to activity, pain brought on by breathing in, or pain associated with symptoms like dizziness, palpitations, tingling, or difficulty swallowing ¹. In such cases, consider causes of chest pain other than angina, such as gastrointestinal or musculoskeletal pain ¹.
• Diagnostic Considerations: A normal resting 12-lead electrocardiogram (ECG) does not rule out a diagnosis of stable angina ¹. Arrange blood tests to identify conditions that may exacerbate angina, such as anaemia ¹. A chest X-ray should only be considered if other diagnoses, such as a lung tumour, are suspected ¹.
• Management Pathways:
  • If stable angina cannot be excluded: If clinical assessment indicates typical or atypical angina, offer diagnostic testing ¹. If the diagnosis of stable angina cannot be excluded in primary care, the patient should be routinely referred ². Consider prescribing aspirin 75 mg daily until the diagnosis is confirmed ².
  • If non-anginal chest pain: Unless clinical suspicion is raised by other history or risk factors, exclude a diagnosis of stable angina if the pain is non-anginal ¹. Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment unless there are resting ECG ST-T changes or Q waves ¹.
  • If ACS or stable angina is excluded but cardiovascular risk factors are present: Follow appropriate guidance, such as the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults ¹.
  • If diagnosis is unclear or symptoms persist: If the cause of chest pain cannot be confidently established by clinical features alone, arrange appropriate investigations ². Routinely refer the patient if the diagnosis is unclear, or if there is a clear diagnosis but persistent chest pain despite management in primary care ².
  • Managing identified underlying causes: If a specific underlying cause is identified and the patient does not require admission or specialist referral, manage that cause (e.g., musculoskeletal chest pain with analgesia, non-specific or psychogenic chest pain with reassurance and management of anxiety/depression) ².
  • Investigating other causes after specialist assessment: If significant CAD is not found during invasive coronary angiography or CT coronary angiography, or if reversible myocardial ischaemia is not found during non-invasive functional imaging, investigate other causes of chest pain ¹. Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries ¹.
• Patient Communication: Discuss any concerns the patient may have, including anxiety when the cause of chest pain is unknown, and correct any misinformation ¹. Offer a clear explanation of the possible causes of their symptoms and any uncertainties ¹. Clearly explain the options at every stage of investigation, making joint decisions and taking their preferences into account ¹. Provide individual advice about seeking medical help if they experience further chest pain ¹. If the chest pain is non-cardiac, explain this and refer for further investigation if appropriate ¹.