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Clinical Pathways

Cardiology
Chest pain

Red Flags

Prolonged chest pain > 20mins in last 72 hrs.
Increase in frequency and severity of chest pain.
Chest pain at rest or with minimal exertion.
Presence of - dyspnoea, cyanosis, pallor, hypotension, or sweating.
Acute ECG changes - ST elevation, new LBBB, new ST depression.
Recent onset arrhythmia.
Positive troponin - note may not be elevated within first 8 hours following MI.

Background

Pathway Rationale

  • To ensure appropriate tests performed prior to referral to Cardiology services.
  • To ensure referral letters contain essential information to allow appropriate grading.
  • If patient has chest pain and can perform a treadmill, then a targeted Chest Pain Clinic appointment can be offered.
  • If patient cannot perform treadmill, or if there are complex features or comorbidities then a standard Cardiology OPD appointment (consult with no treadmill on same day) is likely to be more appropriate.

A diagnosis of angina is more likely when the pain:

  • Is located retrosternally or left pectoral region.
  • Is associated with sweating, nausea, or dyspnoea.
  • Radiates to neck, jaw, shoulders, arms, or back.
  • Is related to exertion.
  • Is exacerbated by cold.
  • Is relieved by glyceryl trinitrate use.
  • Is relieved by rest.

A diagnosis of angina is unlikely when the pain:

  • Is continuous or very prolonged pain.
  • Unrelated to activity.
  • Has pleuritic features.
  • Is associated with dizziness or paraesthesias.
  • Is associated with difficulty swallowing.
  • Is related to posture change.

Assessment

  1. Examination
    • Full cardiovascular and respiratory examination required including:
      • Pulse rate and character.
      • Blood pressure.
      • Presence of cardiac murmur.
    • Note: Aortic stenosis is:
      • Typically located right sternal edge and radiates to the carotid arteries may have associated narrow pulse pressure, slow rising pulse, aortic thrill, fourth heart sound.
      • Can be associated with syncope and chest pain.
  2. History
    • History should include:
      • Characterization of pain
      • Exacerbating or relieving factors
      • Associated symptoms
    • Evaluate risk factors and manage:
      • Smoking
      • Hyperlipidaemia
      • Hypertension
      • Diabetes mellitus
      • Personal history of CAD
      • Family history CAD - first degree male relative < 55 years / female < 60 years
    • Useful patient risk assessment tool
    • Note: Beware of atypical presentations - chest pain may not be the presenting complaint - this is more common in:-
      • Patients with diabetes mellitus, due to autonomic dysfunction.
      • Elderly patients may present with malaise, lethargy, and change in mental status.
      • People of South Asian origin may present with sharp chest pain.
  3. Take an ECG as soon as possible:
    • Where possible forward copy of ECG or results to hospital,
    • Do not delay transfer to hospital to record and send the ECG.
    • Normal ECG does not exclude acute coronary syndrome.
    • Compare with past ECG if possible .
    • Note: Consider V4R lead in a situation where the ECG is normal with continuing chest pain
  4. Consider Non-Cardiac Causes
  5. When there is a likely cardiac cause, assess Urgency
    • Red Flags (above) require emergency referral
      • Chest Pain Clinic:
        For patients with chest pain and who can perform a treadmill ECG test - then a Chest Pain Clinic appointment will be appropriate - the consultation will be held in conjunction with a treadmill ECG test.
      • Cardiac OPD - seen according to grading of urgency:
        For patients who cannot perform treadmill ECG test or if there are complex features or comorbidities - then a standard Cardiology OPD appointment will be more appropriate.
      • Note: Advanced age or multiple co-morbidities refer Healthcare in Ageing

Management

  1. Primary Management of Acute Coronary Syndrome
    • Arrange urgent transfer to hospital
      • Administer Aspirin if patient not taking already.
      • Do not delay transfer to hospital to record and send the ECG.
      • Establish IV line.
      • Glyceryl trinitrate spray or sublingual for initial pain relief.
      • IV morphine with metoclopramide may be required for pain control.
      • Avoid IM injections if possible (in case thrombolysis is required).
      • Continuous ECG monitoring if available while being transported.
  2. Interim Treatment Conditions
    • If there is a strong possibility of coronary arterial disease, then consider treatment pending possible appointment:
      • Aspirin
      • Glyceryl trinitrate spray
      • Statin
      • Anti-anginal medication
  3. Cardiology OPD
  4. Driving Considerations
    • Refer to NZTA regulations and advise patient.
    • Consider employment and financial implications for vocational drivers

Information

Pathway developed by the following people:

Name Position

Dr Rick Hudson

GP (Lead)

Dr Calum Young

SMO (Lead)

Dr Jonathan Tisch

SMO

Dr Patrick Crisp

GP

Dr Kingsley Logan

SMO

Dr Cecile DeGroot

GP

Wendy Bryson

Cardiac Speciality Nurse

Mairi Lucas

Cardiac Speciality Nurse

Shelley Pakoti

Cardiac Speciality Nurse

Dr Joanne Simson

GP Liaison

Jacky Maaka

Admin Support

Kerrie Freeman

Facilitator

Richard Harrison

IT Analyst

Trevor Richardson

DSA Manager

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.