How should I differentiate between aortic dissection and other causes of acute chest pain in a primary care setting?

In a primary care setting, the primary approach to differentiating aortic dissection from other causes of acute chest pain focuses on identifying any suspected serious cause that necessitates urgent hospital admission, rather than definitive diagnosis in the community ¹. Aortic dissection is considered a life-threatening condition associated with a high risk of death or serious morbidity, requiring immediate admission ¹,².

Key indicators for urgent hospital admission for acute chest pain, including suspected aortic dissection, are:

• Respiratory rate greater than 30 breaths per minute ¹.
• Tachycardia greater than 130 beats per minute ¹.
• Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for the individual) ¹.
• Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia) ¹.
• Altered level of consciousness ¹.
• Raised temperature, especially if higher than 38.5°C ¹.

Initial assessment in primary care should include:

• Measurement of blood pressure, pulse rate, temperature, breathing rate, oxygen saturation, and level of consciousness ¹. These assessments are also recommended by the National Early Warning Score (NEWS2) and can be applied to acutely ill people with chest pain where the cause is unknown ¹.
• Taking a resting 12-lead electrocardiogram (ECG) as soon as possible ¹,². It is important to note that a normal resting 12-lead ECG does not exclude an Acute Coronary Syndrome (ACS) ².

If there is any suspicion of a serious cause, or any concern regarding the person's general well-being, urgent hospital admission should be arranged ¹. Recording and sending the ECG should not delay transfer to hospital ¹,². If an Acute Coronary Syndrome (ACS) is not suspected, other acute conditions, including life-threatening ones like pulmonary embolism or aortic dissection, should be considered ².