Chest Pain Algorithm

Scope. Adult primary-care guide for patients with chest pain. It supports, but does not replace, clinical assessment or local emergency protocols. Use separate pathways for children, pregnancy and the post-partum period, and for patients with major trauma, active cancer treatment, sickle-cell disease or other specialist circumstances.

Clinical override If clinical suspicion remains high, escalate despite a reassuring score, a normal ECG or normal observations. No score, ECG or set of observations in this pathway is permitted to overrule a clinician who thinks this patient may be having an ACS, a PE or a dissection.

First decision point — is chest pain present now, or was the last episode within the previous 12 hours? Timing sets urgency (NICE CG95)

Pain present nowPossible cardiac features → 999 emergency transfer, regardless of the ECG or the observations

Pain-free, last episode <12 h agoAbnormal ECG, or no ECG available → emergency referral. Normal ECG → urgent same-day hospital assessment

Last episode 12–72 h agoUrgent same-day hospital assessment

Last episode >72 h agoDetailed assessment, ECG and an appropriately timed high-sensitivity troponin through the local pathway; urgency determined clinically. Do not automatically relabel this as stable angina

What must never be used to reassure: a normal ECG does not exclude ACS · reproducible chest-wall tenderness does not exclude ACS, PE or other serious disease · relief after GTN is not diagnostic · a normal oxygen saturation does not exclude PE or ACS · do not use D-dimer to rule out PE when clinical probability is high · do not diagnose anxiety until serious causes have been considered. The physiological thresholds used below (SBP <90, HR <50 or >120, SpO₂ <90%, NEWS2 ≥5) are warning signs, not diagnostic requirements.

Safety

Red Flags — Emergency Exclusion

Done

Screen for life-threatening causes FIRST. Any red flag requires immediate escalation.

Ongoing or recurrent possible ischaemic pain requires emergency transfer — regardless of the ECG or the current observations. Do not wait for a repeat ECG, bloods or imaging before calling 999.

Suspected ACS Pressure, heaviness, tightness or burning — or dyspnoea, epigastric discomfort, nausea, sweating, fatigue, presyncope or syncope, with or without central chest pain. Do not require radiation to the left arm or "crushing" pain: symptom equivalents are particularly common in older adults, women and people with diabetes or CKD (ESC ACS 2023, international) → 999 immediate transfer · do NOT drive them yourself
Aspirin 300 mg chewed for suspected ACS only, unless clear allergy or a major contraindication; withhold if acute aortic dissection is a realistic leading diagnosis and say so on handover. No other antiplatelet or anticoagulant in primary care (NG185). GTN — not if hypotensive or shocked, marked bradycardia or tachycardia, suspected right-ventricular infarction, severe aortic stenosis, or a PDE-5 inhibitor within 24 h (48 h tadalafil). Oxygen only if SpO₂ <94%, target 94–98% (88–92% if at risk of hypercapnic respiratory failure). Follow the local ambulance/ACS protocol.

Acute aortic syndrome / dissection Suspect if pain is sudden and maximal at onset, tearing or severe, radiates to the back, or comes with syncope, focal neurological deficit, pulse deficit, shock, a new aortic regurgitation murmur, connective-tissue disease (Marfan, Ehlers–Danlos) or known aortic disease → 999 immediate transfer; do not delay for tests. A marked inter-arm BP difference supports it (no validated national cut-off) — a normal difference, or the absence of a pulse deficit, does not exclude it. Do not give aspirin or anticoagulation while dissection is a realistic leading diagnosis

Pulmonary embolism Pleuritic pain, breathlessness, haemoptysis, DVT risk factors, tachycardia, hypoxia → 999 if haemodynamically unstable, otherwise same-day emergency assessment

Tension pneumothorax Sudden onset, breathlessness, tracheal deviation, reduced breath sounds, haemodynamic compromise → 999 immediate transfer

Cardiac tamponade Breathlessness, hypotension, muffled heart sounds, raised JVP, history of pericarditis/malignancy → 999 immediate transfer. Do not wait for the complete triad — raised JVP, muffled heart sounds and hypotension are not always all present

Oesophageal rupture Severe pain after vomiting/instrumentation, surgical emphysema, systemically unwell → 999 immediate transfer

Haemodynamic instability Systolic BP <90 mmHg, HR >120 or <50 bpm, oxygen saturations <90%, altered consciousness → 999 immediate transfer. These are warning signs, not exclusion criteria: serious ACS, PE or dissection may occur with entirely normal observations and a normal NEWS2

Acute heart failure Orthopnoea, paroxysmal nocturnal dyspnoea, bilateral basal creps, raised JVP, peripheral oedema → Same-day acute assessment

Pericarditis Sharp pleuritic pain, worse lying flat, better sitting forward, pericardial rub, recent viral illness → Same-day clinical assessment, particularly for a first episode (ECG, troponin, echo, inflammatory markers). Do not assume uncomplicated pericarditis from positional pain alone

Unstable angina Cardiac-sounding pain at rest, crescendo pattern, duration >20 minutes → Same-day emergency assessment

Cancer red flags Persistent unexplained chest pain with weight loss, haemoptysis, hoarseness >3 weeks, supraclavicular lymphadenopathy → Urgent chest X-ray · NICE NG12 and a suspected cancer pathway referral if it suggests lung cancer (or for unexplained haemoptysis at 40 or over)

Sepsis NEWS2 score ≥5, temp >38°C or <36°C, productive cough, systemically unwell → Same-day assessment for possible pneumonia/empyema

Do not delay tests. If ACS, aortic dissection, massive PE, cardiac tamponade or tension pneumothorax is suspected, do not delay emergency transfer for an ECG, blood tests, D-dimer or imaging — they belong in hospital or en route.

Why red-flag screening matters: Chest pain is common in general practice and includes conditions with high mortality if missed (ACS, aortic dissection, massive PE). Time-to-treatment directly affects outcomes in STEMI and aortic dissection. The goal is not to diagnose definitively but to identify who needs immediate hospital assessment. NICE CG95 emphasizes that clinical judgement overrides scoring systems—if it feels wrong, escalate. The harm of a missed ACS far outweighs that of a cautious transfer, which justifies a low threshold for 999.

Diagnose

Risk Stratification — Confirm Cardiac vs Non-Cardiac

Done

Use clinical features and validated tools to stratify risk. Document clearly in notes. Atypical presenters — women, diabetics, the elderly: breathlessness, epigastric pain or 'indigestion' may BE the angina; autonomic features carry the same weight as pain character.

Classify urgency before assigning a diagnosis. New, worsening, prolonged or rest pain must not be classified as stable angina simply because the patient is currently pain-free or the initial ECG is normal.

Anginal equivalents

Cardiac symptoms may be described as dyspnoea, epigastric discomfort, fatigue, nausea, sweating, jaw/neck/back pain, or discomfort in either arm — with or without chest pain

Character

Cardiac: Pressure, heaviness, tightness or burning — in the chest, either arm, jaw, neck, back or epigastrium; "crushing" is one presentation, never a requirement. Non-cardiac: Sharp, stabbing, positional, reproducible on palpation. Avoid using "typical/atypical" as an exclusion rule — describe the symptom pattern and the overall clinical likelihood. Reproducible tenderness lowers the likelihood of ACS but does not exclude ACS, PE, dissection or other serious disease

Onset

Cardiac: Gradual build-up over minutes. Dissection: Maximal at onset (thunderclap). MSK: After exertion/movement

Duration

Angina: 2-10 minutes. ACS: >20 minutes. GORD: Variable, often post-prandial. MSK: Constant or intermittent over days

Exacerbating factors

Angina: Exertion, cold, emotion. PE: Deep breath. Pericarditis: Lying flat. GORD: Large meals, lying down. MSK: Movement, palpation

Relieving factors

Angina: Rest, GTN. GORD: Antacids. MSK: Position change, analgesia. Pericarditis: Sitting forward

Associated symptoms

Cardiac: Sweating, nausea, dyspnoea. PE: Haemoptysis, leg swelling. Pneumonia: Fever, productive cough. Anxiety: Palpitations, paraesthesia, hyperventilation

Cardiovascular risk

Use QRISK3 if not already calculated. Age, smoking, diabetes, hypertension, hyperlipidaemia, family history, CKD

Wells score (PE)

If pleuritic + breathlessness: DVT signs (3), PE most likely Dx (3), HR >100 (1.5), immobilization/surgery (1.5), previous VTE (1.5), haemoptysis (1), malignancy (1). >4 = PE likely

Pain diary

If recurrent: ask patient to record timing, triggers, duration, severity (0-10), relief with GTN/analgesia over 1-2 weeks

PE decision box — two-level Wells (NICE NG158)

PE unlikely · Wells ≤4D-dimer if the result is available and actionable today; consider an age-adjusted threshold over age 50. Negative D-dimer with a low score → stop and consider alternatives. Positive → same-day imaging pathway

PE likely · Wells >4Urgent CTPA (or V/Q) pathway — do not use D-dimer. If imaging will be delayed, consider interim therapeutic anticoagulation per NICE NG158 and the local protocol — take baseline FBC, renal and liver function, PT and APTT first, but do not delay treatment for the results. CTPA is arranged through the local acute medical/ED pathway, not as GP direct access

Pregnant or ≤6 weeks post-partumNeither Wells nor D-dimer is validated — do not use the standard Wells/D-dimer pathway; refer directly to the local maternity/acute VTE pathway. If clinical suspicion is significant, immediate LMWH while objective testing is arranged unless strongly contraindicated (RCOG Green-top 37b)

Any Wells scoreHaemodynamic compromise, severe hypoxia or syncope → 999, whatever the score. A low Wells score never overrides high clinical suspicion

Why risk stratification matters: Only a minority of chest pain in primary care is cardiac, and sending everyone to ED creates long waits and anxiety. Clinical features shift probability: radiation to both arms and sweating raise it; chest-wall tenderness lowers it but never excludes. The two-level Wells score with D-dimer is a validated way to rule out PE when clinical probability is low (NG158). Pain diaries reveal patterns invisible in a snapshot consultation: exertional angina appears as 5-10 minute episodes triggered by identical activities. A raised QRISK3 lowers the threshold for investigation. Documentation protects you medico-legally and guides the next clinician.

Diagnose

Classification — Identify the Underlying Cause

Done

Classify based on examination and risk assessment. Most diagnoses are clinical.

Cardiac ischaemic

Stable angina: Predictable exertional pain, relieved by rest/GTN within 5 minutes, no rest symptoms. Unstable angina: New onset, crescendo pattern, pain at rest >20 minutes

Cardiac non-ischaemic

Pericarditis: Sharp, pleuritic, positional, pericardial rub. Myocarditis: Post-viral, HF features, arrhythmia. Aortic stenosis: Exertional syncope, slow-rising pulse, ejection systolic murmur

Vascular

Acute aortic syndrome: see the step 1 red flag — 999, do not delay for tests. PE: see the PE decision box in step 2 — Wells, then imaging or D-dimer

Respiratory

Pneumonia: Fever, productive cough, creps, dullness. Pneumothorax: Sudden, breathlessness, reduced breath sounds. Pleurisy: Sharp, worse on inspiration, post-viral

Gastrointestinal

GORD: Burning, retrosternal, post-prandial, worse lying down, antacid relief. Oesophageal spasm: Mimics cardiac pain but no ECG changes, may respond to nitrates

Musculoskeletal

Costochondritis: Tender costochondral junctions, reproduced on palpation. Muscle strain: History of overuse/injury, tender muscle, worse on movement. Rib fracture: Trauma, point tenderness, crepitus

Psychological

Panic attack: Sudden onset, palpitations, hyperventilation, paraesthesia, sense of doom, duration <30 minutes. Anxiety disorder: Recurrent, GAD-7 score elevated, triggers identifiable. Do not label anxiety until serious causes have been considered — never at a first presentation without observations and a recorded ECG decision

Other

Herpes zoster: Dermatomal pain before rash, unilateral, burning quality. Referred pain: Cervical radiculopathy (C5-T1), gallbladder disease (right-sided). Cocaine/stimulant-induced: ask the under-50s directly — coronary vasospasm mimics ACS; manage as possible ACS with emergency assessment; drug choices follow the acute cardiology protocol

Why classification drives management: Treatment pathways diverge completely based on cause. Stable angina requires antiplatelet + statin + beta-blocker ± revascularization. GORD requires PPI + lifestyle. Costochondritis requires reassurance and simple analgesia. Giving a PPI to angina delays diagnosis and risks an MI. Giving aspirin to GORD causes bleeding without benefit. The key skill is recognising the main groups — cardiac, musculoskeletal, GI, respiratory, psychological. Most are benign, but the minority with ACS is why we assess carefully. Classification also sets follow-up: suspected angina goes to the local chest-pain pathway; MSK can usually be reviewed later. Accurate labeling reduces patient anxiety (costochondritis sounds less scary than "chest pain of unknown cause") and prevents re-consultations.

Diagnose

Targeted Examination — What to Check

Done

Focused examination to confirm or refute differential diagnoses. Takes 3-5 minutes.

General inspection

Sweating (ACS), distress level, perfusion, pallor (anaemia/shock). Marfanoid habitus — tall, arm span > height, high-arched palate, pectus, arachnodactyly, lens dislocation, aortic regurgitation murmur (aortic risk). Significance: Diaphoresis LR+ 2.0 for ACS

Vital signs

BP both arms (a marked difference suggests dissection — no validated cut-off — but a normal difference does not exclude it), HR (tachy in PE/sepsis/panic, brady in heart block), RR (>20 in PE/pneumonia), SpO₂ — target 94–98% for most acutely ill adults; 88–92% if at risk of hypercapnic respiratory failure, pending blood gases (BTS emergency oxygen 2017), temp, mental state, capillary glucose where clinically relevant. Oxygen treats hypoxaemia, not breathlessness alone — prescribe and document the target range. Repeat the observations if symptoms persist or change. NEWS2: ≥5 supports urgent escalation; it does not define the diagnosis or the disposition

Cardiovascular

JVP (raised in RV failure/tamponade), apex beat (displaced in LVH/cardiomegaly), heart sounds (S3 in HF, S4 in ischaemia, murmurs: AS, AR, MR), pericardial rub (pericarditis), peripheral pulses (absent in dissection/PE). BP differential: Critical sign in dissection

Respiratory

Chest expansion (reduced in pneumothorax), percussion (dull in consolidation/effusion, hyper-resonant in pneumothorax), auscultation (creps in pneumonia/HF, reduced sounds in effusion/pneumothorax, wheeze in asthma). Unilateral findings: Suggest pneumothorax or consolidation

Chest wall

Palpate costochondral junctions (Tietze's syndrome), intercostal muscles (strain), sternum (fracture post-trauma). Reproducible tenderness lowers the likelihood of ACS but does not exclude ACS, PE, dissection or other serious disease

Abdomen

Epigastric tenderness (GORD/PUD/pancreatitis), RUQ tenderness (gallbladder disease). Pulsatile, expansile mass with pain, collapse or shock → 999 — symptomatic or ruptured AAA. An acute red flag, not a screening opportunity

Legs

Clinical signs of DVT (leg swelling plus tenderness along the deep veins) → increases PE probability; peripheral oedema (HF). Clinical signs of DVT: 3 points in the Wells PE score

Skin

Dermatomal rash (herpes zoster—may precede pain by 2-3 days), xanthelasma (hyperlipidaemia), corneal arcus <50 years (familial hypercholesterolaemia). Lipid stigmata: Increase CVD risk

Why examination findings change management: Examination has two purposes: (1) exclude emergencies that need same-day transfer, (2) build confidence in a benign diagnosis. A pericardial rub supports pericarditis, but a new presentation still needs same-day assessment including troponin. Reproducible chest wall tenderness makes ACS less likely but does NOT exclude it (Cochrane review 2010)—combine with history and ECG. Clinical signs of DVT (3 points) with PE as the most likely diagnosis (3 points) give a Wells score of 6 (PE likely) and trigger imaging. A marked inter-arm BP difference supports dissection (no validated cut-off), but a normal difference does not exclude it. The exam is not diagnostic—it shifts probabilities. A normal exam in a high-risk patient (diabetes, 60 years old, crushing pain) still needs investigation. An abnormal exam in a low-risk patient (25, no risk factors, sharp pain) might be costochondritis. Context is everything.

Diagnose

Investigations — What to Test and When

Done

Targeted investigations based on clinical suspicion. Avoid blanket testing.

ECG

Who: All suspected cardiac pain, whatever the age. When: As soon as possible — within 10 minutes in an acute presentation — but never ahead of transfer in a time-critical one. Compare with any previous ECG. Looking for: ST elevation (STEMI → 999), ST depression or T wave inversion (may indicate ischaemia, but does not by itself establish NSTEMI → same-day), new LBBB or other concerning conduction abnormality (→ senior / emergency assessment), AF (assess rate, rhythm, stability and stroke/bleeding risk — anticoagulation per the AF pathway, not automatic), pericarditis (saddle-shaped ST elevation, PR depression). A normal ECG does NOT exclude ACS (NICE CG95) — repeat the ECG if pain persists, recurs or the first ECG is non-diagnostic, and consider right-sided/posterior leads where clinically indicated

Chest X-ray

Who: Suspected pneumonia, pneumothorax, HF, malignancy, persistent unexplained pain. When: Urgent same-day if pneumothorax/HF suspected. Targeted, not routine: the CXR answers a suspected pneumonia, pneumothorax, pulmonary oedema, pleural disease, malignancy or other thoracic cause — it does not rule out ACS or PE. Urgent CXR (within 2 weeks, NICE NG12 (updated April 2026)): aged 40 and over with 2 or more unexplained symptoms, or 1 or more if they have ever smoked (cough, fatigue, breathlessness, chest pain, weight loss, appetite loss). Suspected cancer pathway referral: CXR findings suggestive of lung cancer, or unexplained haemoptysis at 40 and over

Blood tests (if cardiac suspected)

Troponin: hospital test. ACS assessment requires the locally validated high-sensitivity troponin pathway, usually serial testing — a single GP troponin is not a universal rule-out strategy. FBC: Anaemia (may precipitate angina). U&Es: Baseline before ACEi/diuretics. Lipids (non-fasting): Risk assessment. HbA1c: Screen for diabetes. TFTs: Hyperthyroidism can cause angina. NT-proBNP: not for undifferentiated chest pain, but use it when heart failure is suspected (NG106). This is not a panel to send on every chest pain — order only what will change management

Blood tests (if respiratory suspected)

FBC: Raised WCC in pneumonia. CRP: supports assessment of infection; no single value separates bacterial from viral pneumonia or decides referral. D-dimer: only through the PE decision box in step 2, and never when PE is likely (Wells >4). Frequently raised in cancer, infection, pregnancy, recent surgery and hospitalised patients, so a positive result is rarely diagnostic; consider an age-adjusted threshold over age 50. Neither a normal SpO₂ nor a normal ECG excludes PE, and a CXR can suggest an alternative diagnosis but cannot exclude PE. NOT routine: Sputum culture (low yield), viral PCR (does not change management)

QRISK3 / cardiovascular risk

Who: All patients 25-84 years not on statins/with known CVD. Calculate using: Age, sex, ethnicity, smoking, diabetes, BP, cholesterol ratio, BMI, family history, CKD, AF, RA, ED, antihypertensives. Action threshold: ≥10% = offer statin (atorvastatin 20 mg)

Exercise tolerance test

Not GP-initiated — and not a test to diagnose or exclude angina in people without known coronary disease (NICE CG95): CT coronary angiography is first-line. Cardiology may use exercise testing to assess known disease or functional capacity; read it as a functional test, never a rule-out.

CT coronary angiography (CTCA)

NOT GP-initiated. First-line investigation for suspected stable angina where the local pathway offers it (NICE CG95). A normal CTCA makes obstructive coronary disease very unlikely. Ordered by cardiology via RACPC. It is not an acute ACS rule-out test

Avoid over-investigation

Do NOT: Order BNP/NT-proBNP for undifferentiated chest pain (use it when heart failure is suspected — NICE NG106), routine troponin in GP (cannot interpret serial changes), screening echos in asymptomatic patients, stress echo without cardiology guidance, angiography referrals directly (go via RACPC)

Why investigations need clear indications: An ECG is quick and can identify STEMI. A normal ECG does NOT exclude ACS, although combined with low-risk features it lowers the probability. CXR has urgent (2-week) indications under NICE NG12 (updated April 2026): unexplained symptoms at 40 and over, with a lower threshold for anyone who has ever smoked. D-dimer is sensitive but not specific—in an older post-op patient, it will be elevated regardless of PE, creating false reassurance if negative (missed PE) or unnecessary CTPA if positive (radiation + contrast risk). Lipid testing guides primary prevention (QRISK3 ≥10% → offer atorvastatin 20 mg, NG238). Troponin needs a validated high-sensitivity assay and serial algorithm through the local acute pathway — an isolated primary-care troponin is not a universal rule-out. The key question: will this test change my management today? If no, defer to specialist.

Refer

Referral Criteria — When to Escalate

Done

Clear thresholds for when specialist input is needed. Document referral rationale.

ACS urgency is set by the timing box at the top of this pathway — pain now · pain-free <12 h · 12–72 h · >72 h. Use it rather than re-deriving the rule here.

999 Ambulance

Ongoing or recurrent possible cardiac pain · suspected ACS (cardiac-sounding) pain present now, whatever the ECG or observations · suspected acute aortic syndrome · suspected massive PE or haemodynamic compromise · tension pneumothorax · cardiac tamponade · oesophageal rupture · acute pulmonary oedema or severe acute heart failure · shock, syncope, altered mental state, severe hypoxia or malignant arrhythmia · any major diagnostic uncertainty with a potentially life-threatening cause. Physiological instability alongside chest pain (SBP <90, HR <50 or >120, SpO₂ <90%, altered consciousness) is a warning sign to be read in context — not a checklist that must be met

Same-Day Emergency

Unstable angina (cardiac pain at rest), pain-free after suspected ACS within 12 h with a normal ECG, last episode 12–72 h ago, suspected PE (Wells >4, haemodynamic compromise, severe hypoxia, syncope or significant diagnostic uncertainty — see the PE decision box in step 2), acute heart failure (severe breathlessness, orthopnoea, bilateral creps), suspected pneumonia, large pneumothorax (>2 cm), sepsis, moderate-severe pericarditis with effusion signs. NEWS2 ≥5 supports urgent escalation but does not alone determine 999 transfer — clinical judgement and the suspected diagnosis take priority. Call ED or acute medical team

Other urgent non-cardiac causes

Same-day assessment for: severe pneumonia or sepsis · suspected oesophageal rupture · acute chest pain in a patient on active cancer treatment · chest pain in pregnancy or post-partum, or suspected PE in pregnancy (direct maternity/acute discussion) · sickle-cell acute chest syndrome where relevant (fever, chest pain, hypoxia — emergency admission)

Suspected cancer

Lung cancer (NICE NG12 (updated April 2026)): suspected cancer pathway referral for CXR findings suggesting lung cancer, or unexplained haemoptysis at 40 and over. Urgent CXR (within 2 weeks) at 40 and over with 2 or more unexplained symptoms — or 1 or more if they have ever smoked — from cough, fatigue, breathlessness, chest pain, weight loss and appetite loss. Mesothelioma: suspected cancer pathway referral for CXR findings suggesting mesothelioma; urgent CXR at 40 and over with 1 or more of those symptoms if they have ever smoked or been exposed to asbestos. Upper GI cancer: dysphagia at any age (with or without chest pain)

Suspected stable angina (local pathway)

Local suspected-angina / RACPC pathway (timescale per local service; the pathway arranges CT coronary angiography or other testing — CG95): typical or atypical angina, or non-anginal pain with relevant ECG changes or other concern; abnormal ECG (new Q waves, LBBB, ST/T changes), recurrent unexplained chest pain with high-risk features. Refer via e-RS or local pathway

Routine Cardiology

Atypical chest pain + significant cardiac family history (<60 years), confirmed arrhythmia needing specialist input, valvular disease detected on examination (murmur + symptoms), structurally abnormal ECG in young patient (Brugada pattern, hypertrophic cardiomyopathy features). Referral time: 6-18 weeks

Respiratory

Urgent: Recurrent pneumothorax, persistent pleural effusion, suspicion of interstitial lung disease (crackles + breathlessness). Routine: Chronic pleuritic pain without clear cause, recurrent pneumonia same lobe (? obstruction)

Gastroenterology

Suspected cancer pathway (NICE NG12 (updated April 2026)): new unexplained dysphagia at any age → suspected cancer pathway referral for oesophageal cancer (this replaced urgent direct-access upper-GI endoscopy). Urgent: severe refractory GORD despite 8 weeks full-dose PPI + lifestyle. Routine: GORD not responding to treatment, query Barrett's oesophagus. Suspected cancer pathway referral (NICE NG12 (updated April 2026), recommendations 1.2.1 and 1.2.7): aged 55 and over with weight loss plus dyspepsia, reflux or upper abdominal pain. Consider non-urgent direct-access endoscopy (NICE NG12 (updated April 2026)): aged 55 and over with treatment-resistant dyspepsia; also 55 and over with nausea or vomiting plus weight loss, reflux, dyspepsia or upper abdominal pain, or upper abdominal pain with a low haemoglobin. Other alarm features (weight loss, vomiting, anaemia) need prompt assessment.

Psychologist / NHS Talking Therapies

Recurrent chest pain with panic features (GAD-7 ≥10, PHQ-9 ≥10), health anxiety, post-cardiac-event PTSD. Self-referral available in most areas. Distinguish panic attacks, panic disorder, GAD, health anxiety and post-ACS distress (NICE CG113)

Primary Care Management

Costochondritis (clear MSK features, reproducible tenderness), GORD (typical symptoms, responding to PPI), anxiety-related chest pain (low risk, normal investigations, psychological triggers), viral pleurisy (post-URTI, improving spontaneously), stable angina controlled on medication (annual review — earlier reassessment if symptoms change)

Why referral thresholds matter: RACPC was designed to reduce inappropriate ED attendances and speed access to diagnostics for stable angina, with access to CTCA; waiting times depend on the local service. Many with stable angina are managed medically, but cardiology input confirms the plan. NICE NG12 sets its suspected-cancer referral thresholds at a cancer risk (positive predictive value) of about 3%. Same-day PE referrals prevent death because untreated PE carries a high mortality. Most costochondritis settles with reassurance and simple measures in primary care. The skill is triaging accurately: send sick patients fast, manage well patients locally, and document why you chose your pathway.

Treat

Treatment — Drug Ladder and Symptom Control

Done

Treatment depends on underlying diagnosis. This section covers primary care management after exclusion of emergencies.

Do not use this pathway for new, changing, crescendo or rest pain until ACS has been appropriately excluded. Everything below assumes the red-flag screen in step 1 and the timing rules in step 6 have been worked through.

Suspected Stable Angina (awaiting RACPC)

Symptom Relief

GTN spray PRN

1–2 sprays (400–800 micrograms) sublingual PRN — sit down first (syncope risk). Also use BEFORE predictable triggers (hills, cold, sex). Warn: headache, dizziness, flushing. Avoid in severe AS, HOCM. ⚠ NEVER within 24h of sildenafil/vardenafil (48h tadalafil) — profound hypotension: ask men proactively, and if they've taken one and get chest pain → no GTN, 999 and tell the crew. For established stable angina, follow the patient's own GTN action plan — a repeat dose after 5 minutes, then 999 if pain persists 5 minutes later. If chest pain is present now and ACS is possible, call 999 immediately — do not wait to see whether GTN works; response to GTN is not a diagnostic test

Antiplatelet

Aspirin 75 mg OD

Consider when stable angina is clinically likely, after bleeding-risk assessment and checking existing aspirin (CG126). Avoid if active PUD or high bleeding risk; consider PPI if dyspepsia history.

High-Intensity Statin

Atorvastatin 80 mg OD

For established CVD (confirmed coronary disease, previous MI/revascularisation, ACS) — lower dose if interactions, adverse-effect risk or preference (NG238); target LDL ≤2.0 or non-HDL ≤2.6 mmol/L. Not automatic for suspected angina before diagnosis. LFTs at 3 months.

Step 1Beta-blocker OR calcium-channel blocker (CG126) — choose by comorbidity, contraindications and preference. Beta-blocker: bisoprolol 5 mg OD, usually 5–10 mg (SPC). CCB: amlodipine, or rate-limiting diltiazem MR/verapamil. Doses per local formulary. Monitor HR, BP. Asthma: usually avoid a beta-blocker — use a CCB (COPD is not a bar).

Step 2Not tolerated → switch class; not controlled → combine a beta-blocker with a dihydropyridine CCB (amlodipine 5 mg OD, increase to 10 mg; or felodipine, MR nifedipine). Do not routinely combine a beta-blocker with a rate-limiting CCB (diltiazem or verapamil) — bradycardia and heart-block risk; verapamil with a beta-blocker is contraindicated

Step 3Add long-acting nitrate Isosorbide mononitrate MR 30 mg OD, increase to 60 mg. Ensure nitrate-free period (asymmetric dosing: 8am dose only) to avoid tolerance. Warn: headache common initially

Step 4Specialist options (cardiologist-initiated) If beta-blocker and CCB are contraindicated or not tolerated: long-acting nitrate, ivabradine (per indication, rhythm, EF and product criteria), nicorandil or ranolazine. OR consider revascularization (PCI or CABG) if refractory symptoms

CT coronary angiography is the first-line investigation for suspected stable angina where available through the local pathway (arranged via RACPC, not by the GP). It is not an acute ACS rule-out test.

GORD / Oesophageal Chest Pain

First-Line PPI

Lansoprazole 30 mg OD

Take 30 minutes before breakfast. Full dose for 4 weeks, or 8 weeks for severe oesophagitis (CG184); 2-week PPI washout before H. pylori testing. Step down to PRN or low-dose (15 mg) if effective. Review need annually (avoid long-term high-dose without indication)

Alternative PPI

Omeprazole 20 mg OD

If lansoprazole not tolerated. Or try H2 antagonist: Famotidine 40 mg nocte (if PPI contraindicated — ranitidine withdrawn from UK market 2020). Generally less effective than a PPI.

Costochondritis / MSK Pain

Simple Analgesia

Ibuprofen 400 mg TDS

Not default — consider paracetamol or topical NSAID first. If oral NSAID: lowest dose, shortest time, gastroprotection by risk; avoid or caution with CV disease, hypertension, renal impairment, GI bleeding/ulcer, anticoagulant/antiplatelet, heart failure, frailty, pregnancy

Alternative NSAID

Naproxen 500 mg BD

If ibuprofen ineffective. Or paracetamol 1g QDS (less effective but safer in elderly/comorbidities). Avoid opiates—no evidence of benefit, risk of dependence

Topical

Ibuprofen gel QDS

Apply to affected area. Lower systemic absorption than oral. Useful if oral NSAIDs contraindicated. Avoid on broken skin

Suspected Pericarditis

Anti-Inflammatory

Same-day assessment First

New suspected pericarditis needs same-day assessment (ECG, troponin, echo, inflammatory markers; exclude myocarditis, ACS, PE) — do not assume uncomplicated pericarditis from positional pain alone. NSAID and colchicine choice, dose and duration follow acute/cardiology advice (colchicine: renal/hepatic function, interactions, weight). Large effusion or tamponade risk → refer urgently

Anxiety-Related Chest Pain

Psychological

CBT / NHS Talking Therapies Referral

Per NICE CG113 for panic disorder or GAD, once serious causes have been considered. Self-referral or GP referral. Teaches breathing techniques, challenges catastrophic thinking.

Pharmacological (if CBT insufficient)

Sertraline 50 mg OD

First-line SSRI for GAD. Increase to 100 mg at 4 weeks if needed (max 200 mg). Warn: initial anxiety increase first 1-2 weeks, 6-8 weeks for full effect. Review at 2, 4, 8, 12 weeks. Continue 6-12 months after remission

Next steps: see Stable angina · MI secondary prevention · Pulmonary embolism · GORD and acid reflux · Anxiety disorders · Acute cough and chest infections

Why treatment ladders improve outcomes: Optimised medical therapy is the foundation of stable angina care before revascularisation is considered. Beta-blockers or calcium-channel blockers reduce angina symptoms (CG126). GTN response is not diagnostic — pain persisting after GTN in suspected ACS means 999, and relief does not exclude ACS. Atorvastatin 80 mg is the NICE dose for established CVD (NG238); it is not automatic for suspected angina before diagnosis. GORD: a full-dose PPI for 4 or 8 weeks is both diagnostic and therapeutic; failure prompts reassessment (CG184). Costochondritis: reassurance and simple analgesia; most settles with time — an oral NSAID is not the default. Over-medicalizing MSK pain increases anxiety and re-consultation rates. Anxiety-related chest pain: psychological therapy per NICE CG113 is effective once serious causes are considered. SSRIs take several weeks to work (CG113). The error is treating everyone the same—individualize to diagnosis.

Lifestyle

Lifestyle Interventions — Treatment, Not Afterthought

Done

Lifestyle advice per NICE prevention guidance — alongside, not instead of, indicated secondary-prevention drugs.

Smoking cessation Single most important intervention. Refer to NHS Stop Smoking Service; offer NRT, varenicline or cytisine/bupropion per local guidance.

Cardiac rehabilitation Supervised exercise and education programme after ACS or revascularisation; improves outcomes, exercise tolerance and quality of life. All ACS/revascularization patients should be offered

Mediterranean diet Reduce saturated fat (<7% total calories), increase fruit/veg (5+ portions/day), oily fish 2x/week, nuts/seeds, olive oil. Supports, but is not equivalent to, indicated statin therapy.

Weight loss (if BMI ≥25) Target 5-10% body weight reduction. Lowers BP and improves lipids and insulin sensitivity. Refer to tier 2 weight management if BMI ≥30 or ≥27.5 with comorbidities.

Alcohol reduction Keep within 14 units/week, spread over 3+ days. Excessive alcohol raises BP, triglycerides, risk of cardiomyopathy. Brief intervention helps. Use AUDIT-C to screen

Physical activity 150 minutes moderate-intensity aerobic exercise per week (e.g., brisk walking 30 mins 5x/week) + strength training 2x/week. Reduces cardiovascular risk. Prescribe via exercise referral schemes where available

Stress reduction For anxiety-related chest pain: mindfulness, yoga, progressive muscle relaxation. Headspace/Calm apps. Evidence base weaker than CBT but low-cost adjunct.

Sleep hygiene 7-9 hours/night. Poor sleep (OSA, insomnia) is linked to higher CVD risk. Screen for OSA if BMI >35 + snoring + daytime somnolence (Epworth score >10). Treat insomnia non-pharmacologically (CBT-I) before hypnotics

GORD-specific Avoid large meals, fatty/spicy foods, caffeine, alcohol, chocolate. Elevate head of bed 15-20 cm. Weight loss if overweight. Eat 3 hours before lying down. Stop smoking (weakens lower oesophageal sphincter)

Posture (MSK pain) Avoid slouching, heavy lifting, repetitive reaching. Ergonomic workstation review. Physiotherapy referral for persistent MSK pain (self-referral available in most areas). Stretches for pectoralis/intercostal muscles

Why lifestyle is treatment, not advice: Smoking cessation is one of the most important secondary-prevention measures. A Mediterranean-style diet supports cardiovascular prevention but does not replace indicated statin therapy. Regular physical activity lowers cardiovascular risk. Weight loss lowers blood pressure. The error is relegating lifestyle to a leaflet—it should be offered with specific targets, follow-up, and referral to services (Stop Smoking, weight management, cardiac rehab), alongside, not instead of, indicated secondary-prevention drugs. Stop Smoking Services improve quit rates compared with willpower alone. Cardiac rehabilitation should be offered after ACS or revascularisation. Adherence is the challenge: motivational interviewing, written action plans and follow-up calls help.

Safety

Follow-Up & Safety-Netting — When to Review

Done

Structured follow-up prevents missed deterioration. Clear safety-netting empowers patients to re-present appropriately.

Suspected angina (awaiting RACPC)

Early review (timing set by local RACPC waits and symptom burden): Check GTN use, medication tolerance, escalating symptoms. Do not treat the patient as safe to remain in primary care indefinitely while awaiting RACPC. 2 weeks: a named clinician chases the RACPC appointment if no date has arrived. Then: a dated review with a named owner and a stated purpose — not an open-ended "review every 2 weeks until cardiology". Safety-net: Return immediately if pain at rest, nocturnal symptoms, GTN ineffective

GORD on PPI trial

4 weeks: Assess symptom response. If resolved, continue 8 weeks total then step down. If persistent, reassess: dysphagia at any age, or aged 55 and over with weight loss plus reflux, dyspepsia or upper abdominal pain = suspected cancer pathway referral (NICE NG12 (updated April 2026), recommendations 1.2.1 and 1.2.7); aged 55 and over with treatment-resistant dyspepsia = consider non-urgent direct-access endoscopy (NG12). 3 months: Attempt step-down to PRN or low-dose. Annual review if long-term PPI needed

Costochondritis / MSK

2 weeks: Review if not improving (most settle with simple measures and reassurance). Persistent >4 weeks: Consider alternative diagnosis (rib stress fracture, Tietze's, referred pain). Physiotherapy if >6 weeks. Safety-net: Return if severe worsening, breathlessness, fever (infection/PE)

Anxiety-related pain

2 weeks (if started SSRI; within 1 week, then weekly for the first month, if under 30 — NICE CG113): Monitor for worsening anxiety, suicidal ideation. 4 weeks: Assess early response. 8 weeks: Full effect. 12 weeks: Consider increase/switch if inadequate response. 6-12 months remission before tapering. NHS Talking Therapies review as per service (usually 6-12 weekly sessions)

Pericarditis (after same-day assessment)

Follow the acute/cardiology plan: NSAID and colchicine choice, dose and duration as advised by the acute team or cardiology, not a fixed GP course. Review: symptom improvement, no signs of effusion (breathlessness, tachycardia, muffled heart sounds); ask about recurrence. Refer urgently if: Worsening breathlessness, fever, haemodynamic compromise

Cardiovascular risk modification

3 months (if new statin): Check lipids (secondary prevention: aim LDL ≤2.0 mmol/L or non-HDL ≤2.6 mmol/L; primary prevention: >40% reduction in non-HDL cholesterol — NICE NG238), transaminases at baseline, within 3 months and at 12 months (<3× ULN is not a reason to stop; ≥3× ULN → recheck and review, stop if persistent), CK if muscle pain. Annual review: BP, lipids, HbA1c (if diabetic), medication adherence, lifestyle. QRISK3 recalculation every 5 years

Recurrent chest pain (benign causes excluded)

3 months: Review if pain pattern changing. New red flags (rest pain, nocturnal symptoms, exertional syncope) warrant urgent reassessment. Consider cardiology referral if diagnostic uncertainty persists despite normal initial work-up

999 Safety-Net

Call 999 if: chest pain that could be cardiac is present now — do not wait to try GTN or to time the pain; chest pain occurring at rest or becoming more frequent or more prolonged; sudden severe pain maximal at onset; pain with syncope or neurological symptoms; persistent or worsening breathlessness; breathlessness with low oxygen sats; palpitations with dizziness or collapse; coughing blood; new unilateral chest pain with breathlessness (pneumothorax/PE); systolic BP <90 mmHg. Someone with established angina follows their GTN action plan — repeat dose at 5 minutes, 999 if pain persists

Same-Day GP Safety-Net

Contact GP same-day if: pain at rest (previously only exertional), GTN no longer effective, worsening breathlessness, new leg swelling (DVT/PE concern), fever + chest pain (infection), vomiting blood, black stools (GI bleed), severe anxiety preventing function

Who owns the follow-up

Document who is responsible for reviewing ECGs, blood results, imaging and referral outcomes, with a named clinician and a date. Do not rely solely on the patient to chase an urgent investigation or an appointment — book the review, flag the result to the named clinician, and record what happens if the patient does not attend

Re-referral triggers

Re-refer urgently if: previously benign chest pain now has cardiac features (exertional, radiation, sweating), new ECG changes, escalating symptoms despite medication, patient anxiety overwhelming despite reassurance + normal tests (consider cardiology reassurance)

A normal ECG, a negative initial blood test or reproducible tenderness does not by itself exclude a serious diagnosis if symptoms persist, recur or evolve. Say this explicitly to the patient and write it in the notes.

Why follow-up and safety-netting save lives: Some ACS presents initially with atypical symptoms and a normal ECG and declares itself later. Early follow-up catches this subgroup. A small proportion of GORD non-responders have malignancy (especially age 55 and over)—hence the NG12 reassessment. Costochondritis that persists >4 weeks may be rib fracture, Tietze's, or referred cervical spine pain—reassessment can change the diagnosis. SSRIs increase suicidal ideation early in treatment in a minority (especially under-30s)—hence early review, within 1 week for under-30s (NICE CG113). Safety-netting reduces re-consultation anxiety ("I don't want to bother the GP") while preventing inappropriate re-presentations ("Is this normal?"). Specific triggers ("pain at rest, GTN ineffective") are clearer than vague advice ("come back if worried"). The medico-legal protection is secondary but real—"Patient advised to re-attend if symptoms persist beyond 2 weeks" is documented evidence of safe practice. Regular review supports medication adherence and risk-factor control (NICE NG238).

❤️ Chest Pain

Red Flags — Emergency Exclusion

Risk Stratification — Confirm Cardiac vs Non-Cardiac

Classification — Identify the Underlying Cause

Targeted Examination — What to Check

Investigations — What to Test and When

Referral Criteria — When to Escalate

Treatment — Drug Ladder and Symptom Control

Suspected Stable Angina (awaiting RACPC)

GORD / Oesophageal Chest Pain

Costochondritis / MSK Pain

Suspected Pericarditis

Anxiety-Related Chest Pain

Lifestyle Interventions — Treatment, Not Afterthought

Follow-Up & Safety-Netting — When to Review