Chest pain accounts for 6% of all new attendances to the Emergency Department in the UK. There is a varied differential diagnosis and some very important emergencies not to be missed.

BACKGROUND

Acute chest pain is a common presenting complaint in patients attending general practice, Emergency Departments (EDs) and Medical Assessment Units (MAUs). It accounts for 6% of all new attendances at EDs in the UK (Goodacre et al, 2004). 

Ischaemic heart disease is responsible for 38% of all adult deaths in the UK (Allender et al, 2008). It is estimated that there are 96,000 new cases of angina and 146,000 new cases of myocardial infarction each year in the UK (Allender et al, 2008). Early management of ischaemic heart disease in the UK has been revolutionised by evidence based guidelines. Acute chest pain may be the only clue of a life-threatening condition and all such patients should be urgently assessed.

Patients presenting with acute chest pain are at risk of being inappropriately discharged home following inadequate assessment, with potentially catastrophic consequences: 6% of patients presenting with acute chest pain are discharged from EDs with missed prognostically important myocardial damage (Collinson et al, 2000). A careful history and examination will often suggest the cause in non-cardiac chest pain. Many causes of non-cardiac chest pain require immediate treatment to avoid serious sequelae. 

A medium-sized district general hospital can expect to see 50 cases of pulmonary embolism (PE) each year. PE is easily missed and is the leading cause of maternal death in the UK (The Confidential Enquiry into Maternal and Child Health (CEMACH), 2007). Chest pain may be caused by gastrointestinal disorders, but acute chest pain should not be assumed to be due to gastrointestinal disease until serious cardiac syndromes have been properly ruled out, especially in older adults.

Top 5 differential diagnoses:
  1. Acute Coronary Syndrome
  2. Pulmonary Embolism
  3. Aortic dissection
  4. Pneumothorax
  5. Pneumonia

Complete the tasks to learn more about Chest pain and some other Cardiac presentations. Remember to always consider and actively exclude the top five differential diagnoses.

Finally if you have any doubts you should seek senior advice, and RCEM state all adults (>17yrs) with non-traumatic chest pain require review by an ED senior prior to discharge.


Learning Outcomes from Completing the Tasks

  • Recognise various causes of chest pain in the Emergency Department.

  • Formulate a management plan for various Emergency Department causes of chest pain

  • Investigate and manage a suspected NSTEMI appropriately as per NICE guidelines

  • Identify the limitations of some of the investigations for chest pain

  • Interpret ECGs in the Emergency Department


Tasks

Complete the following before the face-to-face session:

TASK 1: Decision-Making in the ED

Duration: 14 mins

This is a short introductory lecture developed by Southampton ED for it's junior doctors which highlights some of the key principles in decision-making in the Emergency Department when considering chest pain. Although they talk about thrombolysis for a STEMI, the gold standard is now PCI.

Task 2: NICE Guidance on Chest Pain

Duration: 20 mins

Familiarise yourselves with the NICE guideline on Chest Pain. Click on the following link for the NICE guideline on Chest pain of recent origin.

 

TASK 3: Low-risk 'Rule Out' Pathways

Duration: 45 mins

Having referred to the NICE guideline please click on the screenshot and complete this RCEM Learning module (login required for a certificate, but you can complete it without logging in).

TASK 4: ECG Interpretation

Duration: 30 mins

This is short video which again was developed by Southampton ED for it's junior doctor induction. It gives a good overview of ECG interpretation. A quick revision!

TASK 5: More ECG Interpretation

Duration: 40 mins

This task requires membership of DNUK

Again this covers all the basics for ECG interpretation. Click on the screenshot or the link below. For more detailed ECG teaching please click on the UHL ED Moodle ECG course. There will be an ECG quiz at your first teaching session.


#EM3 Content

Lightning Learning:

SIMBLOG:


Case Discussion

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

A 70 year old male presents to majors with central chest pain, which radiates to the left side...

Additional Resources

Here are some extra resources that offer further insight into cardiovascular care:

Resus council:

The ALS manual is a good source of information. This becomes available when you do an ALS course or can be found on the Resus Council UK website.


Course Feedback

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 5th January 2017