Dr Alan Begg considers the possible diagnoses of a patient presenting with chest pain: is it angina, indigestion, a heart attack, or a PE?
Read this article to learn more about:
- identifying the cause of chest pain from a patient’s presenting symptoms
- examinations that can be useful in primary care
- urgent cases that require immediate referral.
The quote ‘Listen to your patient, he is telling you the diagnosis’ is attributed to the Canadian physician William Osler. This is especially relevant when a patient presents with chest pain, where differentiation of the type of pain and its likely cause is crucial. Of all patients presenting to primary care with chest pain (1–2% of all consultations), around 15% are thought to be non-specific (i.e. the cause is unknown).1 Chest pain can be caused by potentially life-threatening disease requiring immediate admission to hospital. In other situations where immediate admission may not be indicated, a full clinical assessment in primary care (and possibly secondary care) to determine the cause and ensure appropriate management is important.
A 63-year old man, who was recently made redundant from the offshore oil industry, presents to primary care reporting that, on two consecutive weekends, he was aware of a ‘twinge’ like pain over his midsternal region while mowing his lawn. The pain did not radiate, he was not nauseated, and there were no other associated features. The discomfort seemed to ease quickly if he stopped what he was doing. He has no past medical or family history of note and he stopped smoking 30 years ago. On examination, he is in sinus rhythm, his blood pressure is 132/84 mmHg (phase 5), and auscultation does not reveal any murmurs. His haemoglobin is within normal limits, his cholesterol level does not suggest familial hypercholesterolaemia, and the reading from a 12-lead electrocardiogram (ECG) is normal.
The likely diagnosis is anginal chest pain.
Anginal pain is described as:2
- 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 within about 5 minutes.
The typicality of chest pain can be categorised as follows:2
- typical angina—all three of the features listed above are present
- atypical angina—two of the features listed above are present
- non-anginal chest pain—one or none of the features listed above is present.
A previous history of coronary disease, personal risk factors, and a family history of premature coronary heart disease will increase the likelihood of a diagnosis of angina.2
Practitioners should be aware that NICE Clinical Guideline (CG) 95 on Chest pain of recent onset: assessment and diagnosis (CG95)2 advises that an exercise ECG should not be used to diagnose or exclude stable angina for people without known coronary artery disease. Offer 64-slice CT coronary angiography if the clinical assessment indicates typical or atypical angina, or if the assessment indicates non-anginal chest pain but 12-lead resting ECG indicates ST-T changes or Q waves.2
A diagnosis of stable angina is unlikely when the chest pain is:2
- continuous or very prolonged and/or
- unrelated to activity and/or
- brought on by breathing in and/or
- associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing.
If the chest pain has any of the features listed above, other causes of chest pain such as gastrointestinal disease or musculoskeletal pain should be considered.
The patient needs to be assessed at a rapid access chest pain clinic. If this is not available locally, the patient should be referred to cardiology services.
The patient was referred to the local rapid access chest pain clinic, where an exercise tolerance test showed ST depression in the lateral chest leads at moderate workload, confirming a diagnosis of stable angina. Following angiography, a drug-eluting stent was inserted into the identified suspect lesion. He was started on long-term prophylactic medication, and advised to achieve his ideal body weight. He is now symptom free.
A 40-year-old manual worker with excessive alcohol intake has previously visited the GP practice complaining of ‘indigestion’ and ‘heartburn’, but has found that self-medication with antacids controls his symptoms. He presents as an emergency in the practice on a Monday morning with a severe stabbing-like pain over his lower sternum, radiating through to his back. He has found some relief by ‘belching’ and although he is anorectic, antacid liquid did not make a difference to the pain. On examination, there is no localising tenderness, liver function tests are normal (including gamma‑glutamyl transferase levels), and his amylase level is slightly elevated at 102 U/L (the normal range is 0–100 U/L).
This patient’s symptoms are likely to be due to dyspepsia.
Patients often use the term ‘indigestion’ to describe any symptom that is food-related. Dyspepsia covers a range of symptoms arising from the upper gastrointestinal (GI) tract but has no universally accepted definition. The British Society of Gastroenterology defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper GI tract; in itself it is not a diagnosis.
Dyspepsia symptoms are typically present for 4 weeks or more, and include upper abdominal pain or discomfort, heartburn, nausea, or vomiting.3 In primary care, dyspepsia is defined more broadly to include people with recurrent epigastric pain or acid regurgitation with or without bloating, nausea, or vomiting.
Causes of dyspepsia include peptic ulceration, oesophagitis, upper-GI cancers, and gastro‑oesophageal reflux disease (GORD). GORD is a chronic condition where gastric juices from the stomach flow up into the oesophagus; heavy alcohol use is a risk factor for GORD. Functional dyspepsia refers to cases when the cause of the symptoms is unknown.4
NICE Quality Standard 96 on Dyspepsia and GORD in adults (QS96) states that ’Adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non-urgent direct access endoscopy.’5
If the patient has dysphagia, or if they are aged over 55 years with weight loss and have upper abdominal pain, reflux, or dyspepsia; offer urgent direct access to upper GI endoscopy (to be performed within 2 weeks) to investigate possible oesophageal or stomach cancer.6 People who present with both dyspepsia and significant acute gastrointestinal bleeding should be referred immediately (on the same day) to a specialist.3
Management in unselected cases invariably involves testing for Helicobacter pylori and full-dose empirical proton-pump inhibitor therapy.
The patient underwent gastroscopy, which subsequently revealed significant oesophagitis, but there was no evidence of dysplasia and tests did not reveal the presence of H. pylori. His symptoms eventually settled with high-dose proton-pump inhibitor therapy; however, efforts to encourage him to moderate his alcohol intake have so far been unsuccessful.
An overweight 54-year-old woman presents to primary care complaining of a constant pain over the right side of her chest that started 2 days after a long car journey. She tells you that before the trip, she had had an irritating, non-productive cough, but the pain was felt not to be pleuritic in nature as it did not catch her breath on deep inspiration. She did feel more breathless than usual when she walked. She says that there is no pain in her legs and her ankles are not swollen. Auscultation of her lung fields reveals coarse crepitations at both bases.
A possible diagnosis in this patient is pulmonary embolism.
A thrombus that has formed in either the systemic veins or the right side of the heart can detach and embolise into the pulmonary arterial system causing a pulmonary embolism (PE). Unexplained breathlessness is usually the main presenting symptom, although chest pain, which can be pleuritic in nature, and haemoptysis can arise once infarction has occurred. Clinical features of a deep venous thrombosis (DVT) may be absent.
If a patient presents with signs and symptoms of a possible pulmonary embolism, a full medical history should be taken and a full physical examination carried out. A chest X-ray should be performed to exclude other possible causes for the symptoms.7
Two-level PE wells score
If a PE is suspected, a two-level PE Wells score should be used to estimate the clinical probability of a PE. Clinical features, and the associated point scores are listed below:
- clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) [3 points]
- an alternative diagnosis is less likely than PE [3 points]
- heart rate >100 beats per minute [1.5 points]
- immobilisation for more than 3 days or surgery in the previous 4 weeks [1.5 points]
- previous DVT/PE [1.5 points]
- haemoptysis [1 point]
- malignancy (on treatment, treated in the last 6 months, or palliative) [1 point]
A score of >4 points suggests that PE is likely, while a score of ≤4 points suggests that PE is unlikely.
If the score indicates that PE is likely, the following actions should be taken:7
- immediate computed tomography pulmonary angiogram (CTPA) or
- immediate interim parenteral anticoagulant therapy followed by a CTPA if this cannot be carried out immediately
- consider a proximal leg vein ultrasound if the CTPA is negative and a DVT is suspected.
If the probability of PE is unlikely based on the two-level PE Wells score, a D-dimer test should be performed, and if the result is positive, an immediate CTPA should be arranged, or interim parenteral anticoagulation commenced if CTPA cannot be carried out immediately.7
In this case management will depend on the two-level PE Wells score or D-dimer test if indicated. Referral pathways will vary from area to area but a chest X-ray may give an indication of current lung disease.
A chest X-ray performed in the acute medical assessment unit showed changes at the right base of the lung, and a subsequent CTPA revealed bilateral pulmonary emboli. She was discharged to her home on oral anticoagulation with no plans in place for hospital follow up.
A 70-year-old man presents to primary care reporting that yesterday he experienced a burning pain travelling up his sternal region from his epigastrium. He tells you that initially, he was able get some relief by crouching forward but during the night the pain became much more severe, and he was nauseous and sweating profusely. A family history reveals that his father had died of a myocardial infarction at the age of 64 years. On examination, he appears sweaty and pale. His pulse is over 100 bpm and low volume, and his blood pressure is 100/70 mmHg (phase 5). A 12-lead ECG suggests elevation of the ST segment across the chest leads, so an emergency response ambulance is necessary.
The likely diagnosis of this patient is an acute ST-segment-elevation acute coronary syndrome.
NICE CG95 addresses the assessment and diagnosis of people with recent acute chest pain or discomfort suspected to be due to the range of conditions covered by the term acute coronary syndrome (ACS).2
The following symptoms may indicate ACS:2
- pain in the chest and/or other areas (for example, the arms, back, or jaw) lasting longer than 15 minutes
- chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
- chest pain associated with haemodynamic instability
- new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes.
There should be no difference in symptom assessment between male and female patients or ethnic groups and response to glyceryl trinitrate should not be used to make a diagnosis of ACS.2
The pain associated with a myocardial infarction is often severe and described as ‘gripping’ or ‘crushing’ in nature.
An early chest computed tomography (CT) can be considered to exclude other diagnoses such as a pulmonary embolism or aortic dissection.2 A chest X-ray can be considered to help exclude pulmonary oedema, pneumonia, or pneumothorax.2
Emergency referral is required if ACS is suspected and the patient currently has chest pain, or if they are currently pain free, but have had chest pain in the last 12 hours and a resting 12-lead ECG is abnormal.2 Same day urgent assessment is required if the patient has had chest pain in the last 12 hours, but is now pain free and 12-lead ECG is normal, or if the last episode of pain was 12–72 hours ago. Similarly, if there are signs of complications of ACS such as pulmonary oedema and the pain has resolved, referral should be as an emergency or as an urgent same-day assessment based on clinical judgment. People who have had a recent episode of ACS and develop further chest pain should be referred to hospital as an emergency.2
Confirm the diagnosis based on:
- the clinical features and nature of the chest pain
- a 12-lead ECG—serial if necessary, and a review of previous recordings
- the rise and/or fall of cardiac troponin.
Confirmation of diagnosis can be done in either primary or secondary care; however a second troponin measurement will likely be done in secondary care.
In this case, emergency reperfusion therapy is required ideally by primary percutaneous coronary intervention.8
The patient’s admission troponin-I level was 0.639 μg/L, and after 3 hours this had risen to 0.779 μg/L (the normal range given by the laboratory performing the test was 0.015 to 0.045 μg/L). A primary percutaneous coronary intervention revealed extensive coronary heart disease and the three most severe stenoses were treated with drug-eluting stents. After discharge, he continued to have episodes of chest pain both at rest and on the slightest exertion, so he subsequently underwent coronary artery bypass grafting.
The cause of chest pain may not be immediately apparent on presentation. A full clinical history and examination is required, and action should be taken on the basis of the presumptive diagnosis. The clinician should, however, be prepared to review this diagnosis if the symptoms or clinical condition change and take appropriate action as indicated.
- NICE. Chest pain. NICE Clinical Knowledge Summaries. NICE, 2015.
Available at: cks.nice.org.uk/chest-pain
- NICE. Chest pain of recent onset: assessment and diagnosis. NICE Clinical Guideline 95. NICE, 2010 (last updated 2016). Available at: www.nice.org.uk/cg95
- NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. NICE Clinical Guideline 184. NICE, 2014. Available at: www.nice.org.uk/cg184
- Tack J, Talley N. Functional dyspepsia—symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol 2013: 10 (3); 134–141
- NICE. Dyspepsia and gastroesophageal reflux disease in adults. NICE Quality Standard 96. NICE, 2015. Available at: www.nice.org.uk/qs96
- NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: www.nice.org.uk/ng12
- NICE. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE Clinical Guideline 144. NICE, 2012 (last updated 2015). Available at: www.nice.org.uk/cg144
- Scottish Intercollegiate Guidelines Network. Acute coronary syndrome. SIGN 148. Edinburgh: SIGN, 2016. Available at: www.sign.ac.uk/sign-148-acute-coronary-syndrome.html