Summary of Chest Pain Triage in Primary Care

Urgent referral to A&E is needed for patients presenting with:

  • ACS: crushing/squeezing chest pain at rest, possibly accompanied by nausea, sweating, shortness of breath or dizziness, pain radiation from left arm to jaw may be present.
  • Aortic aneurysm dissection – symptoms include sharp tearing pain, dyspnoea, syncope, a feeling of impending doom.
  • PE – includes symptoms of sharp sudden pain in a patient with a history of recent inactivity/stasis – perhaps recent long-haul travel, recent surgical procedure under general anaesthetic or hospital admission which has restricted normal level of activity, breathlessness.

Chest pain not necessarily requiring urgent transfer to A&E:

  • Angina – similar symptoms to ACS, but pain experienced on exertion and relieved at rest (possibly with a history of CVD). If the patient is unstable patient should be treated along the lines of ACS. Treat initially with GTN.
  • Chest infection/pleurisy; patient will present with pain on moving or breathing, presents as sharp central pain. Patient may also have a fever. This can be safely treated in primary care setting.
  • Pericarditis; again, symptoms as pleurisy, to be treated with NSAIDs if suitable for patient, consider outpatient ECG.
  • GORD – burning pain, retrosternal. May have a long history, possibly associated with particular foods. Not particularly urgent unless presenting with malaena or haematemesis. Patient may require gastroscopy; primary care may involve PPIs or H2 blockers.

It is vital to take a detailed history, as well as appropriate observations (BP, ECG, pulse, respiratory rate, temperature).

P – Provocation/palliation – what triggers the pain? What relieves it?

Q – Quality – what is the pain like? Stabbing, crushing, aching, dull, tearing. Also use pain scale.

R – Radiation – where does the pain begin, and where does it radiate to?

S – Site – what’s the location of the pain?

T – Timing – when did the pain start? What was the duration? How many episodes have there been? When did the episodes start? Is it getting better or worsening?

Also, record any accompanying symptoms such as dizziness, nausea/vomiting/burping, feeling of impending doom, syncope.

Symptoms suggesting ACS need urgent referral to hospital. If this is the case, the patient should be given 300mg aspirin and high-flow oxygen.

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