Assessment of stable chest pain of suspected cardiac origin

Presentation with stable chest pain

• stable angina should be diagnosed based on one of the following:
  • clinical assessment alone or
  • clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia)
    
    
• if people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see tables), further diagnostic investigation is unnecessary. Manage as angina

Table 1: Non-anginal chest pain - % likelihood of CAD

Table 1 represents people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely

Table 2: Atypical anginal pain - % likelihood of CAD

Table 3: Typical angina - % likelihood of CAD

• for men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
• For women older than 70, assume an estimate of 61-90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed
• Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD)
• Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre)
• Lo = Low risk = none of these three
• Note:
  • These results are likely to overestimate CAD in primary care populations. If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.

Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal

Other features which make a diagnosis of stable angina unlikely are when the chest pain is:

• 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. Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain)

Reference:

• 1) NICE (March 2010). Chest pain of recent onset.