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Assessment of stable chest pain of suspected cardiac origin

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Presentation with stable chest pain

  • stable angina should be diagnosed based on one of the following:
    • clinical assessment alone or
    • clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia)

  • if people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see tables), further diagnostic investigation is unnecessary. Manage as angina

Table 1: Non-anginal chest pain - % likelihood of CAD

Men

Men

Women

Women

Age (years)

Lo

Hi

Lo

Hi

35

3%

35%

1%

19%

45

9%

47%

2%

22%

55

23%

59%

4%

45%

65

49%

69%

9%

49%

Table 1 represents people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely

Table 2: Atypical anginal pain - % likelihood of CAD

Men

Men

Women

Women

Age (years)

Lo

Hi

Lo

Hi

35

8%

59%

2%

39%

45

21%

70%

5%

43%

55

45%

79%

10%

47%

65

71%

86%

20%

51%

Table 3: Typical angina - % likelihood of CAD

Men

Men

Women

Women

Age (years)

Lo

Hi

Lo

Hi

35

30%

88%

10%

78%

45

51%

92%

20%

79%

55

80%

95%

38%

82%

65

93%

97%

56%

84%

  • for men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
  • For women older than 70, assume an estimate of 61-90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed
  • Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD)
  • Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre)
  • Lo = Low risk = none of these three
  • Note:
    • These results are likely to overestimate CAD in primary care populations. If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.

Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal

Other features which make a diagnosis of stable angina unlikely are when the chest pain is:

  • continuous or very prolonged and/or
  • unrelated to activity and/or
  • brought on by breathing in and/or
  • associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing. Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain)

Reference:


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