How To Manage Chest Pain In Primary Care?
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Initial assessment
Start with ABCDE if acutely unwell. Otherwise, take a focused history:
- Onset: Sudden or gradual? At rest or exertion?
- Character: Sharp, dull, tight, burning, tearing?
- Radiation: Arm, jaw, back?
- Associated symptoms: Dyspnoea, nausea, palpitations, syncope, sweating
- Timing: Constant or intermittent? Duration?
- Exacerbating/relieving factors: Worse with breathing, position, exertion, food?
Consider risk factors: IHD, smoking, diabetes, HTN, recent surgery, travel, cancer history.
Red flags
Refer same-day or call 999 if:
- Suspected ACS (e.g. crushing chest pain, ECG changes)
- Suspected PE (e.g. pleuritic pain + SOB + risk factors)
- Suspected aortic dissection (e.g. tearing pain radiating to back + unequal pulses)
- Haemodynamic instability
- New oxygen requirement or low saturations
- Suspected pneumothorax
Differential diagnosis
Cardiac
- ACS
- Pericarditis (pleuritic, better sitting forward, pericardial rub)
- Aortic dissection
Respiratory
- Pulmonary embolism
- Pneumothorax
- Pneumonia/pleuritis
GI
- GORD
- Oesophageal spasm
- Peptic ulcer disease
- Biliary colic
Musculoskeletal
- Costochondritis
- Rib strain or trauma
Psychogenic
- Panic attacks
- Anxiety
Examination
- General appearance: clammy, distressed?
- Obs: HR, BP, sats, RR, temp
- Cardio: heart sounds, murmurs, signs of failure
- Respiratory: breath sounds, crepitations, tracheal deviation
- Chest wall tenderness
Investigations in primary care
- ECG: look for signs of ACS, pericarditis, PE
- Bloods: FBC, U&Es, CRP, D-dimer (if available)
- CXR: if considering pneumonia, do not delay emergency care
- Troponin: usually secondary care
- Consider spirometry or Holter later for non-acute presentations
Management
- If life-threatening: call 999
- If ACS suspected: initiate aspirin 300 mg (if not contraindicated)
- Musculoskeletal: NSAIDs, reassurance
- GORD: trial PPI
- Anxiety: safety netting, brief intervention, follow-up
Safety netting
Always:
- Advise to return or call 999 if pain worsens, changes, or new symptoms (e.g. SOB, dizziness)
- Document red flag exclusion
- Arrange timely follow-up if diagnosis uncertain