Signs and Symptoms

Query personal history of ischemic heart disease (IHD), acute myocardial infarction (AMI), coronary revascularisation or any other cardiovascular disease.

Symptoms, assess

• Conditions likely to precipitate pain
• Duration of symptoms (when did episodes of pain first start)
• Duration of pain (how long does each episode last)
• Exacerbating/relieving factors
• Response to short acting nitrates, if any
• Family history of heart disease
• Co-morbidities (hypertension, hyperlipidaemia, diabetes)
• Smoking history

Examination:

• Heart rate, rhythm, heart sounds, murmur
• Chest examination
• Blood pressure
• BMI

Anginal pain is:

• Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms
• Precipitated by physical exertion
• Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes

Symptoms that make coronary disease unlikely are:

• Unrelated to activity
• Brought on by inspiration
• Accompanied by difficulty in swallowing

Differential Diagnoses

• Gastro-oesophageal reflux disease
• Musculoskeletal pain
• Pleuritic or infective pain

• Pain at rest with a history suggestive of infarction, especially if pain persists for longer than 15 minutes
• Pain with haemodynamic instability

The presence of any of these findings should prompt the clinician to consider acute admission

Bloods:

• Full blood count
• Renal
• Lipids
• HbA1c
• Liver function test
• Thyroid function test

Electrocardiogram (ECG) is mandatory (but can be normal in up to 90% of patients with typical angina)

Chest x-ray if relevant signs or symptoms

If you suspect pain of cardiac origin, consider starting the following medication where appropriate and safe to do so:

• Aspirin, see 2.9 Antiplatelet drugs
• Beta-blocker (calcium channel blocker if beta-blocker contraindicated)
• Statin, see 2.12 Lipid regulating drugs
• Sublingual nitrate, see 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs
• Lifestyle advice

For men older than 70 with atypical or typical symptoms, assume an over 90% likelihood of coronary disease

For women older than 70, assume an estimate of 61 – 90% except women at high risk and with typical symptoms where a risk of above 90% should be assumed

High risk = smoking, diabetes and cholesterol above 6.5

Low risk = none of these

ECG changes increase likelihood of coronary artery disease

Referral Criteria

• If recent onset (within the last 3 months) refer to Rapid Access Chest Pain Clinic:
  • A resting ECG and blood results are mandatory for this service

Please use the single cardiology referral form

• If onset longer than 3 months, refer routinely to cardiology

• Patients with a Coronary Artery Disease (CAD) risk less than 10% should have other causes of chest pain considered first and not be referred to RACPC
• Patients with a CAD risk of 90% or more should be managed as stable angina and a referral may not be necessary
• Other patients with a clinical suspicion of exertional angina should be referred

Table 1 Percentage of people estimated to have coronary artery disease according to typicality of symptoms, age, sex and risk factors

Referral Instructions

** Please note attaching an ECG is a mandatory requirement for referrals to both the RACPC and General Cardiology chest pain referrals (see investigations) **

For Rapid Access Chest Pain clinic

• E-mail: plh-tr.RACPC@nhs.net

For Cardiology

e-Referral Service Selection

• Specialty: Cardiology
• Clinic Type: Not Otherwise Specified
• Service: DRSS-Western-Cardiology- Devon ICB-15N / DRSS-Western-Cardiology-Cornwall-Devon ICB-15N

Referral Forms

For Rapid Access Chest Pain Clinic

Please use the single cardiology referral form

For Cardiology

DRSS Referral form

Pathway Group

This guideline has been signed off on behalf of NHS Devon

Publication date: December 2015

Updated: September 2023