What guidelines should I follow for the follow-up of patients with atypical chest pain after initial evaluation?

Follow-up management of patients with atypical chest pain after initial evaluation should include:

• Reassess the likelihood of cardiac origin: Use clinical judgement to determine if myocardial ischaemia is suspected and consider further diagnostic testing if stable angina cannot be excluded clinically ².
• Exclude serious causes: If acute coronary syndrome (ACS) has been excluded and no urgent hospital admission is required, manage according to the underlying cause or refer for specialist assessment if diagnosis remains unclear or symptoms persist ¹,².
• Investigations: Arrange appropriate investigations such as resting 12-lead ECG and blood tests (e.g., full blood count to exclude anaemia) to identify exacerbating conditions ¹,². Do not routinely perform chest X-ray unless other diagnoses (e.g., lung cancer) are suspected ¹,².
• Manage underlying causes: For musculoskeletal chest pain, consider analgesia such as paracetamol or NSAIDs; for psychogenic or non-specific chest pain, provide reassurance, information, and consider managing anxiety or depression ¹.
• Provide clear information and shared decision-making: Explain possible causes, uncertainties, and options for further investigations in accessible language, addressing patient concerns and preferences ².
• Referral criteria: Refer urgently if symptoms worsen or new concerning features develop; routinely refer within 2 weeks if diagnosis remains unclear or symptoms persist despite management ¹.
• Risk factor management: If stable angina is excluded but cardiovascular risk factors are present, follow relevant NICE guidelines on cardiovascular disease and hypertension ².