Current chest pain, or pain in the last 12 h with an abnormal or unavailable ECG, or signs of complications: call 999. Do not rely on a normal examination to exclude ACS.
Think could be cardiac if
- Central, heavy or tight pain, possibly radiating to arm, neck or jaw
- Associated sweating, nausea or breathlessness
- Brought on by exertion, eased by rest or GTN
- Known IHD with new or worsening symptoms
Also consider (and act on)
- Aortic dissection: tearing pain to the back, unequal BP: 999
- PE: pleuritic pain, breathlessness, risk factors
- ACS can be atypical in women, older people and diabetes
- Do not give aspirin at home unless ACS strongly suspected and advised
Stable exertional (angina)
- GTN, refer rapid-access chest pain
- Secondary prevention
- Safety-net advice
Recent (within 12 h), settled
- Same-day assessment
- ECG and troponin
- Do not sit on it
Call 999 now
- Ongoing or severe pain
- Signs of ACS, sweating, unwell
- Aspirin 300 mg while waiting
GP approach
1
1. Risk stratify
History first: character, radiation, triggers, duration, associated features and cardiac risk factors.
History first: character, radiation, triggers, duration, associated features and cardiac risk factors.
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2
2. Examine and ECG
Observations, BP in both arms if dissection possible. A resting ECG does not exclude ACS: if recent pain, arrange urgent assessment.
Observations, BP in both arms if dissection possible. A resting ECG does not exclude ACS: if recent pain, arrange urgent assessment.
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3
3. Suspected stable angina
Refer to a chest pain or cardiology clinic for assessment (CT coronary angiography is first-line per NICE). GTN for symptoms with instructions on when to call 999.
Refer to a chest pain or cardiology clinic for assessment (CT coronary angiography is first-line per NICE). GTN for symptoms with instructions on when to call 999.
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4
4. Safety-net
Call 999 if pain is severe, prolonged, recurs at rest, or with breathlessness, syncope or feeling very unwell.
Call 999 if pain is severe, prolonged, recurs at rest, or with breathlessness, syncope or feeling very unwell.
GTN advice for patients
- Repeat dose after 5 min if pain persists
- Call 999 if still in pain 5 min after the second dose
- Sit down (risk of light-headedness)
Pitfalls
- Reassuring on a single normal ECG after pain has settled
- Missing dissection or PE as the cause
- Giving aspirin in undifferentiated chest pain
- Underestimating atypical presentations
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026