Chest pain

A 48 year old man presents to his GP with chest pain. Over the last 3 months he has noticed chest pain when out walking – he is a postman. He is getting it more frequently now, and he feels it is affecting his work as he needs to rest when he gets it. He feels more short of breath when he gets the pain.  The pain is in the centre of his chest with no radiation.  He has no associated features.

Definition of angina 

Angina is chest pain (or constricting discomfort) caused by an insufficient blood supply to the heart muscle.

• Stable angina usually occurs predictably with physical exertion or emotional stress, and is relieved within minutes of rest, or with a dose of sublingual glyceryl trinitrate.
• Unstable angina is new onset angina, usually within 24 hours, or abrupt deterioration in previously stable angina, often occurring at rest. Unstable angina usually requires immediate admission to hospital (if chest pain occurring at rest) or urgent referral to a cardiologist.

Causes of Angina 

• Coronary artery disease (most common).
• Valve disease (for example aortic stenosis).
• Hypertrophic obstructive cardiomyopathy (HOCM).
• Hypertensive heart disease.

Assessment

History

• Presenting complaint: Chest pain/discomfort – at rest? On exertion?  Any radiation?
• Associated features – nausea, SOB, lightheaded, palpitations, sweating?
• Pain relieved by rest/GTN?

PMH

• Any cardiac history.
• Hypertension.
• Diabetes.

FH

• Cardiac (especially if first degree relatives under the age of 50).

SH

• Smoking.
• Alcohol or other possibly relevant factors.

Examination

General  Pale, sweaty – does the patient look well/unwell

• Cardiac
• Pulse – rate/regular?  Listen to heart sounds, any murmurs, any signs cardiac failure Blood pressure
• Examination may be normal

Initial Investigations

• 12 lead ECG
• Blood tests e.g. FBC (anaemia can precipitate angina), Lipids, glucose, thyroid function (hyperthyroidism could precipitate angina)

Red flag 

If chest pain occurs at rest, which you suspect may be cardiac in nature, then urgent action must be taken – immediate hospital admission, consider oxygen/GTN spray/aspirin/analgesia.

Referral^2,3,4

Patients with suspected stable angina should be referred for urgent secondary care assessment to confirm if any CAD present.  In Lothian, the Rapid Access Chest Pain Clinic (RACPC) ensures these patients to are assessed within a week (if criteria met)³

RACP criteria for referral

• Discomfort in the anterior chest/jaw/arm lasting less than 30 mins.
• Symptoms provoked by walking or other cardiovascular exercise.
• Symptoms relieved by rest or GTN.

Patient not suitable for RACPC if:

• Symptoms lasting longer than 30 minutes.
• Symptoms occur predominantly at rest.
• Patient attended a cardiology clinic within the previous 6 months.
• Normal myocardial perfusion scan, normal CT coronary angiogram or normal coronary angiogram within the last 3 years.

Clinicians who suspect stable angina should consider prescribing appropriate medications as detailed below. 

Consider urgent hospital admission for people with the following symptoms:

• Pain at rest (which may occur at night).
• Pain on minimal exertion.
• Angina that seems to be progressing rapidly despite increasing medical treatment.

Indications for early referral to a cardiologist include:

• Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina.
• ECG (electrocardiograph) evidence of previous myocardial infarction or other significant abnormality.
• Newly diagnosed atrial fibrillation and angina.
• Heart failure and angina.
• Aortic stenosis  – suspect if ejection systolic murmur (ESM) heard.
• Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG).

Further reasons to refer people to a cardiologist include:

• Doubt about the diagnosis.
• The presence of several risk factors or a strong family history.
• The person’s preference for referral.

Management of stable angina

Lifestyle advice

• Smoking Cessation
• Maintain a healthy weight.
• Increase in physical activity levels within limits set by symptoms.
• Alcohol consumption to within recommended levels.

Drugs

• Sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms of angina and for use before performing activities known to cause symptoms of angina.
• A beta-blocker or a calcium-channel blocker as first-line regular treatment to reduce the symptoms of stable angina.
• Second-line treatment such as a long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine.

Drugs are also used for secondary prevention of cardiovascular events:

• Antiplatelet treatment should be considered in all people with stable angina. For most people this will be 75 mg Aspirin daily.
• An angiotensin-converting enzyme (ACE) inhibitor should be prescribed for people with coexisting hypertension, heart failure, asymptomatic left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction in line with current guidance, unless this is contraindicated or not tolerated. Treatment with an ACE inhibitor should be considered for people with stable angina and diabetes mellitus.
  •        A statin should be offered in line with NICE guidance on lipid modification.
  •        Treatment for hypertension should be offered in line with NICE guidance on hypertension.

Summary

This patient was diagnosed with suspected stable angina and commenced on appropriate treatment and referred to the RACPC.  He underwent a CT Coronary Angiogram, which confirmed the diagnosis.  His symptoms were initially controlled by medications.

A few months later, he presented to his GP with chest pain at rest.  He was immediately referred in to hospital and treated for acute coronary syndrome (ACS). (See SIGN Guideline 148 for most recent management of this, which is not covered by this handbook).

References

1. NICE-CKS on angina (summary and detail)
2. NICE-CKS scenario recommendation, angina
3. NHS Lothian RefHelp
4. SIGN Guideline on stable angina (pdf)