How to manage a 35-year-old patient presenting with chest pain in a general practice setting in New Zealand?

From the Guidelines

Managing a 35-year-old patient with chest pain in a New Zealand general practice requires a prompt and structured approach to rule out life-threatening conditions, with a focus on history, physical examination, and targeted investigations, as outlined in the ACR Appropriateness Criteria for nontraumatic chest wall pain 1. The initial assessment should include a rapid evaluation of vital signs and a focused history to determine the characteristics of the chest pain, associated symptoms, and risk factors for cardiovascular disease.

• Ask about pain characteristics (onset, location, radiation, quality, severity)
• Inquire about associated symptoms (shortness of breath, nausea, sweating)
• Assess risk factors for cardiovascular disease
• Review previous medical history A targeted physical examination should be performed, including:
• Heart and lung auscultation
• Blood pressure measurement in both arms
• Assessment for signs of cardiac failure An ECG should be obtained immediately in the practice, and point-of-care troponin testing should be considered if available 1. If there are any concerning features suggesting acute coronary syndrome, emergency services (111) should be called for urgent transfer to hospital. For stable patients with atypical symptoms and low cardiovascular risk, other causes such as musculoskeletal pain, gastroesophageal reflux, or anxiety should be considered, and appropriate symptomatic treatment should be prescribed while arranging follow-up investigations, such as exercise stress testing, which can be accessed through the local District Health Board. It is essential to maintain a low threshold for referral to emergency services when uncertain, as even young patients without obvious risk factors can experience cardiac events, and musculoskeletal chest wall pain, such as costochondritis, is a common cause of chest pain in this age group, as noted in the ACR Appropriateness Criteria 1.

From the Research

Assessment of Chest Pain

• The first step in managing a 35-year-old patient presenting with chest pain in a general practice setting in New Zealand is to take a thorough patient history, perform a physical examination, and conduct a 12-lead electrocardiogram (ECG) and cardiac biomarkers test, as outlined in the study 2.
• The mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) can help differentiate cardiac from non-cardiac pain, as mentioned in the study 2.
• Evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces, and chest infections are important components of the physical examination, as stated in the study 2.

Diagnostic Tests

• A 12-lead ECG should be interpreted within 10 minutes of first medical contact to identify ST elevation myocardial infarction (STEMI), as recommended in the study 2.
• High-sensitivity troponins can improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI), as discussed in the study 3.
• The use of high-sensitivity troponin T (hs-TnT) assay can help identify ischemia in patients previously undiagnosed by conventional testing, particularly in women, as mentioned in the study 3.

Management of Chest Pain

• The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention (PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available, as outlined in the study 2.
• Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin), and cardiac monitoring, as stated in the study 2.
• Clinical suspicion of coronary artery disease (CAD) is crucial, even with normal initial investigations, as demonstrated in the case study 4.

Importance of Clinical Suspicion

• The case study 4 emphasizes the importance of clinical suspicion in the diagnosis of coronary artery disease, even with unremarkable ECG and cardiac enzymes.
• The study 5 highlights the need to recognize early signs of myocardial ischemia, including subtle ECG abnormalities beyond STEMI.
• The study 6 discusses the impact of sex on symptoms among patients presenting with acute coronary syndrome or acute myocardial infarction, emphasizing the need for a nuanced approach to diagnosis and management.