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Practice Guidelines

Assessment of recent onset chest pain or discomfort of suspected cardiac origin: summary of NICE guidance

BMJ 2010; 340 doi: (Published 24 March 2010) Cite this as: BMJ 2010;340:c1118
  1. Angela Cooper, senior research fellow1,
  2. Adam Timmis, professor of clinical cardiology 2,
  3. Jane Skinner, consultant community cardiologist3
  4. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE
  2. 2Barts and the London Queen Mary’s School of Medicine and Dentistry, London E1 2AD
  3. 3Department of Cardiology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP
  1. Correspondence to: A Cooper angela.cooper{at}

    Why read this summary?

    Chest pain is very common, and in the United Kingdom about 1% of visits to a general practitioner, 5% of visits to the emergency department, and 25% of emergency hospital admissions are for this symptom.1 Chest pain has many causes, and when the cause could be cardiac in origin, appropriate and timely assessment and diagnostic investigation are needed. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin.2


    NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the experience and opinion of the Guideline Development Group (GDG) on what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Two separate diagnostic pathways are presented. The first is for people with acute chest pain in whom an acute coronary syndrome is suspected. The second is for people with intermittent stable chest pain in whom stable angina is suspected.

    Acute chest pain and suspected acute coronary syndrome

    Initial clinical assessment and referral to hospital

    • Consider the history of chest pain, the presence of cardiovascular risk factors, history of ischaemic heart disease, and any previous investigations.[Based on moderate quality evidence from meta-analyses in one systematic review and one small cohort]

    • Assess for any of the following symptoms, which may indicate an acute coronary syndrome:

      • - Pain in the chest or other areas that lasts longer than 15 minutes

      • - Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or a combination of these

      • - Chest pain associated with haemodynamic instability

      • - New onset chest pain, or abrupt deterioration in previously stable angina, with frequent recurrent pain that occurs with little or no exertion and often lasts longer …

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