The video version of this podcast can be found here: https://youtu.be/so97zARpmME This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline on recent onset cardiac chest pain [CG95], always focusing on what is relevant in Primary Care only. I am not giving medical advice; this episode is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148·      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e·      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P·      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D·      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3 There is a YouTube version of this and other videos that you can access here: ●       The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The resources consulted can be found here:Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis guideline [CG95] can be found here:●      https://www.nice.org.uk/guidance/cg95/chapter/recommendationsIntro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] ●       Music provided by Audio Library Plus ●       Watch: https://youtu.be/aBGk6aJM3IU ●       Free Download / Stream: https://alplus.io/halfway-through  TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to go through the NICE guideline on recent onset cardiac chest pain [CG95], always focusing on what is relevant in Primary Care only. Right, without any further ado, let’s jump into it.We are going to start by looking at the assessment and diagnosis of recent acute chest pain, suspected to be an acute coronary syndrome. The term ACS covers a range of conditions including unstable angina, ST‑segment-elevation myocardial infarction (or STEMI) and non‑ST‑segment-elevation myocardial infarction (or NSTEMI).We will not cover the management of these conditions, given that this would be done in the hospital setting.The first obvious thing is to check whether the patient has chest pain at the time of the consultation. If the patient is pain free, we will check when their last episode was, particularly if they have had pain in the last 12 hours. We will see the importance of this and the impact on the possible management later.In order to decide whether the chest pain is cardiac we will consider:·      the history ·      the presence of cardiovascular risk factors·      a history of ischaemic heart disease and ·      any previous treatment and investigations for chest pain. Symptoms suggestive of an ACS are:·      pain in the chest and/or, for example, arms, back or jaw, lasting longer than 15 minutes·      chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these·      chest pain associated with haemodynamic instability and·      new onset chest pain, or abrupt deterioration in previously stable angina, with frequent and recurrent chest pain on little or no exertion, and with episodes often lasting longer than 15 minutes. ·      But we will bear in mind that not all people with an ACS present with central chest pain as the predominant feature and that ·      we should not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS. If we suspect an ACS, we will refer them to hospital. But NICE makes different recommendations as to who we should send to the emergency department and who we should send for urgent same-day hospital assessment. So, if we suspect an ACS, we will send the patient as an emergency to the emergency department if:·      they currently have chest pain or·      they are currently pain free, but had chest pain in the last 12 hours, and a resting 12‑lead ECG is abnormal or not available Otherwise, in the absence of clinical concerns, we will refer for urgent same-day assessment if:·      they had chest pain in the last 12 hours, but are now pain free with a normal ECG or·      the last episode of pain was 12 to 72 hours ago We will also refer people for a hospital assessment if:·      the pain has resolved and·      there are signs of complications such as pulmonary oedema.But for this group of patients we will use clinical judgement to decide whether referral should be as an emergency or for urgent same-day assessment. Right, so that is fairly clear, we will be referring straightaway patients who have had cardiac chest pains in the last 72 hours, regardless of ECG, or whether they have complications, using our clinical judgement as to whether they are for the emergency department or for urgent same day assessment. But what do we do if we see someone who had cardiac chest pains more than 72 hours ago and who have no complications such as pulmonary oedema?NICE says that we should:·      carry out a clinical assessment·      confirm the diagnosis with an ECG and blood troponin level and·      take into account the length of time since the suspected event when interpreting the troponin level, using clinical judgement to decide whether referral is necessary and how urgent this should be. And this is where it can get a little controversial. Should we be doing troponin levels in primary care, bearing in mind that the results may not be available the same day? If we are worried enough about an ACS to be doing troponin levels, should we be asking our hospital colleagues to assess the patient anyway? What would be the medicolegal implications in Primary Care if the patient had a serious cardiovascular event in the intervening period? And all this not to speak that many primary care organisations do not allow or recommend troponin testing in the primary care setting anyway. As NICE says, it always comes back to us. They say, that we should use our clinical judgement to decide whether referral is necessary and how urgent this should be. So, it will depend on the presentation and our assessment of the risk. And it may very well be that you take the view that most, if not all, of your patients should have their troponin levels checked in hospital.Is there anything else that we should do before referring them to hospital? Well, we should take an ECG as soon as possible, as long as this does not delay transfer to hospital and we will offer immediate treatment. Let’s look at the ECG considerations first. ECG changes that make the diagnosis of an ACS more likely are:·      ST‑segment changes·      Deep T wave inversion or ·      A presumed new left bundle branch block consistent with an acute STEMI ·      Also, even in the absence of ST‑segment changes, we will have an increased suspicion of an ACS if there are other changes such as Q waves and T wave changes but·      Always bearing in mind that we should not exclude an ACS just because of a normal ECG. And now, let’s look at the immediate treatment that we should give in a way that is appropriate to the circumstances. So, as soon as we suspect an ACS, we should: ·      Offer pain relief, which may be achieved with either sublingual or buccal GTN, but we will offer intravenous opioids such as morphine, particularly if an acute MI is suspected. ·      Offer a single loading dose of 300 mg of aspirin as soon as possible unless there is clear evidence that they are allergic to it, ensuring that we also send to hospital with the patient a written record that it has been given. ·      We will not routinely administer oxygen, but we will monitor oxygen saturation, and we will only offer oxygen if:o  oxygen saturation (SpO2) is less than 94% if the patient is not at risk of hypercapnic respiratory failure, aiming for SpO2 between 94% and 98%o  if the patient has COPD and is at risk of hypercapnic respiratory failure, we will aim for a target SpO2 between 88% to 92%, until blood gas analysis is available buto  We also need to be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if it is borderline and that overestimation has been reported in people with dark skin. If an ACS is not suspected, we will consider other causes of the chest pain, some of which may be life-threatening such as a PE, aortic dissection or pneumonia.In these cases, and until a firm diagnosis is made, we will monitor patients with chest pain including:·      review of symptoms and effect of pain relief·      pulse and blood pressure·      heart rhythm·      oxygen saturation and·      repeated ECGs OK, we have covered so far patients presenting with new onset chest pain. But what should we do for people with suspected stable angina who present with intermittent stable chest pain?Let’s have a look at this scenario. We will start the history and examination documenting:·      the age and sex ·      the characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain·      any associated symptoms, such as breathlessness·      any history of angina, MI, or other cardiovascular disease ·      any cardiovascular risk factors and·      we will exclude other causes of chest pain and examine for non-coronary causes of angina (for example, severe aortic stenosis or cardiomyopathy) The diagnosis of stable angina based on our clinical assessment will depend on how typical of angina the chest pain is. And anginal pain has these main three features:·      it is constricting in the chest, or in the neck, shoulders, jaw or arms·      it is precipitated by physical exertion and·      it is relieved by rest or GTN within about 5 minutes. We will call it typical angina if all three features are present.We will call it atypical angina if there are only two of the three features present.And we will call it non-anginal chest pain if only one or none of the features are present.The factors that make a diagnosis of stable angina more likely are:·      increased age·      being male·      other cardiovascular disease or CAD like, for example, a previous MI and ·      cardiovascular risk factors such as:o  smokingo  diabeteso  hypertensiono  dyslipidaemia or ao  family history of premature coronary artery disease On the other hand, features which make a diagnosis of stable angina unlikely are when the chest pain is:·      continuous or very prolonged ·      unrelated to activity ·      brought on by breathing in and / or·      associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowingIn these cases, we will consider other causes of chest pain such as gastrointestinal or musculoskeletal pain. But if there are cardiovascular risk factors, we will still manage them appropriately.If we suspect stable angina:·      we will arrange blood tests to identify conditions which exacerbate angina, such as anaemia, ·      we will only consider chest X‑ray if other diagnoses, such as a lung tumour, are suspected and·      we will arrange an ECG as soon as possible, even though we will not rule out angina just because the ECG is normal. There are a number of ECG changes which may indicate ischaemia or previous infarction. These include:·      pathological Q waves ·      LBBB and ·      ST‑segment and T wave abnormalities (for example, flattening or inversion). If we suspect stable angina: ·      We will consider aspirin until a firm diagnosis is made but we will not offer additional aspirin if they are already taking it regularly or are allergic to it. ·      We will follow the NICE guideline on stable angina while waiting for the results of investigations and you can check the corresponding episode on stable angina on this channel and ·      We will refer to cardiology so that they can be offered the necessary diagnostic testing, such as CT coronary angiography or non-invasive functional testing such as myocardial perfusion scintigraphy or stress echocardiographyWe have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

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