Chest pain - red flag symptoms

Red flag symptoms to look out for in presentations of chest pain, and tips on remote assessment by telephone or video link.

Coronary artery stenosis: a possible cause of chest pain
Coronary artery stenosis: a possible cause of chest pain

Red flag symptoms

  • Exertional
  • Sudden onset
  • Dyspnoea
  • Haemoptysis
  • Significant unintentional weight loss
  • New-onset dyspepsia if aged >55 years
  • History of leg swelling, long-haul flights or any recent periods of immobility
  • Cough for >3 weeks and/or fever

Chest pain is a common presentation in primary care and has a number of differential diagnoses. Diagnosing the cause of chest pain is often not easy because it may have a multifactorial aetiology.

Chest pain should be classified into the following causes:

  • Cardiac
  • Respiratory
  • GI
  • Musculoskeletal
  • Psychological, including anxiety

Life-threatening diagnoses that can present with chest pain include MI, pulmonary embolus, pneumothorax, pleural effusions, dissecting thoracic aortic aneurysm, valvular heart problems, lung cancers, oesophageal cancers, significant anaemia (Hb <8g/dL) and oesophageal perforations.

Pneumonia must also be considered and up-to-date information on COVID-19 can be found on the NICE COVID-19 rapid guideline site, including the guideline on managing suspected or confirmed pneumonia in adults in the community.

Taking a history

Patients who present with chest pain will generally be quite anxious and that is often apparent early in the consultation.

Beginning with an open question, for example, 'Tell me more about the pain,' should reveal a number of features of the pain.

Find out where the site of the pain is and, if necessary, ask the patient to point to this site.

When did it start? Does the pain come on suddenly? How often does the pain occur? What brings it on? Does the pain come on at rest or is it brought on by exertion and if so, what sort of distances cause it?

Is it dull in nature, or sharp? Does it radiate anywhere else? Has there been any history of trauma to the area? Are there any other associated symptoms?

It is important to ask the patient specifically about respiratory symptoms, such as dyspnoea, cough, expectorate, wheeze, haemoptysis or fever.

If relevant, enquire about leg swelling, recent long-haul flights, any recent operations, periods of immobility or use of the combined oral contraceptive pill or HRT.

It may also be relevant to ask about asbestos exposure and a detailed smoking history. Any past cardiac history is important and may be relevant.

Cardiac symptoms will include associated nausea or vomiting, sweating, palpitations, presyncope or syncope.

GI symptoms include associated reflux, burning sensation, pain that is worse after food, nausea, vomiting, haematemesis or black stool.

It is important to ask about unintentional weight loss if a GI cause is suspected. It may also be necessary to enquire about other features of generalised anxiety disorder if this is thought to be the primary problem.

Possible causes

  • Acute coronary syndrome
  • Valvular heart problems, for example, aortic stenosis
  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Lung cancer
  • Pneumothorax
  • Dissecting thoracic aortic aneurysm
  • Costochondritis
  • Anxiety
  • GORD
  • Oesophageal cancer

Remote and face-to-face assessment

Remote assessment
If contacting the patient or family on the telephone, ask:

  • How do they sound? Do they sound in pain?
  • Is there any evidence of respiratory distress? Can they complete sentences?
  • Do they have a BP machine or pulse oximeter? Can they count their own pulse?

If using a video link, check:

  • How do they look - is there any pallor?
  • Is there any evidence of respiratory distress? Can they complete sentences, and is there any pursed-lip breathing?
  • Do they have a BP machine or pulse oximeter?

Face-to-face assessment
Using appropriate personal protective equipment depending on location, check the patient's BP, pulse, pulse oximetry, respiratory rate and temperature. Any evidence of shock, hypoxia or fever may require urgent referral to secondary care.

Check for any evidence of central or peripheral cyanosis. Auscultate the heart sounds, listening for any added sounds or murmurs.

Percuss the chest wall - is there any dullness to percussion?

Auscultate the chest. Check for reduced air entry, wheeze or bronchial breathing. Is there any tenderness to palpation of the chest wall? Can the same pain be reproduced?

If abdominal examination is necessary, pay close attention to the presence of anaemia, epigastric masses or focal epigastric tenderness. You may wish to check the patient’s BMI.

It may also be necessary to look for clinical evidence of a DVT.

Investigations

Primary care investigations into the possible aetiology will be guided by the history and examination findings but could include:

  • Blood tests - FBC, U&Es, HbA1c, lipid profile, ferritin, LFTs
  • Plain chest X-ray
  • 12-lead ECG
  • Echocardiogram
  • Testing for Helicobacter pylori
  • Spirometry
  • Peak flow meter and diary
  • Hospital Anxiety and Depression score
  • Secondary care investigations will depend on your differential diagnosis but could include:
  • CT pulmonary angiography
  • CT calcium scoring
  • Myocardial perfusion scan
  • Coronary angiography
  • Upper GI endoscopy
  • Bronchoscopy
  • PET scan

Dr Pipin Singh is a GP in Northumberland. This article first appeared on GPonline on 31 January 2018 and was updated in 2020 to reflect the COVID-19 pandemic

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