What is chest pain?

Chest pain is one of the most common presentations in cardiology and emergency medicine. It encompasses a broad spectrum — from benign musculoskeletal discomfort to life-threatening acute coronary syndromes. The key clinical priority is to rapidly assess whether the pain is cardiac in origin and, if so, whether it represents an emergency.

Types of cardiac chest pain

• Stable angina: Predictable chest tightness or pressure on exertion, relieved by rest or GTN spray within minutes. Caused by fixed coronary narrowings.
• Unstable angina: Angina at rest or with minimal exertion, or new-onset or worsening angina. A medical emergency requiring urgent assessment.
• NSTEMI / STEMI (heart attack): Coronary artery blockage causing myocardial infarction. Elevated troponin confirms myocardial damage.
• Pericarditis: Sharp, positional chest pain worsened by lying flat and relieved by leaning forward. Often viral in origin.

Characteristics of cardiac chest pain

• Central, retrosternal heaviness, pressure or tightness — 'like an elephant sitting on the chest'
• Radiation to the left arm, jaw, neck, back or shoulder
• Associated with breathlessness, diaphoresis (sweating) or nausea
• Brought on by exertion, emotional stress or cold weather
• Relieved by rest or sublingual nitrates (GTN)
• Lasting 2–10 minutes (stable angina) or longer (ACS)

Non-cardiac causes to consider

• Gastro-oesophageal reflux disease (GORD) and oesophageal spasm
• Musculoskeletal pain — costochondritis, rib injury
• Pleurisy and pulmonary embolism
• Anxiety and panic disorder
• Aortic dissection — tearing, severe pain radiating to the back (emergency)

Cardiac assessment is guided by pre-test probability (age, sex, risk factors, pain character) and results of initial tests.

• ECG: First-line investigation. ST-segment changes, T-wave inversion or new LBBB suggest acute ischaemia. A normal ECG does not exclude significant coronary disease.
• High-sensitivity troponin: Rises within 1–3 hours of myocardial injury. Serial measurements at 0 and 1–3 hours rule in/out ACS.
• Echocardiogram: Assesses LV function and regional wall motion abnormalities suggesting prior or ongoing ischaemia.
• Exercise stress echocardiography: Preferred over plain exercise ETT — more sensitive and specific for obstructive coronary disease.
• CT coronary angiography (CTCA): Excellent negative predictive value — a normal CTCA effectively excludes significant coronary disease. Guideline-recommended for stable chest pain with low-to-intermediate risk.
• Coronary calcium score: Quantifies subclinical atherosclerosis. A score of 0 confers very low short-term event risk.

Stable angina

• Anti-anginal therapy: sublingual GTN for acute relief, beta-blockers, calcium channel blockers, long-acting nitrates, ranolazine
• Antiplatelet therapy (aspirin) and statin therapy for all patients with confirmed CAD
• Coronary revascularisation (PCI or CABG) for refractory symptoms or high-risk anatomy

Risk factor modification

• High-intensity statin therapy — target LDL-C <1.8 mmol/L in established CAD
• Blood pressure control — target <130/80 mmHg
• Antiplatelet therapy (aspirin, with or without second antiplatelet)
• Smoking cessation
• Diabetes management
• Cardiac rehabilitation

• Know and manage your cardiovascular risk factors
• Optimise cholesterol — particularly LDL-C
• Control blood pressure and blood sugar
• Don't smoke
• Exercise regularly — 150 min/week moderate activity
• Eat a heart-healthy Mediterranean-style diet
• Maintain healthy weight

For stable or recurring chest pain, obtain a GP referral for specialist cardiology assessment including ECG, echocardiogram and CTCA at HeartWise Cardiology.