CHEST PAIN

General Medical Emergencies 51

(a) ideally this stress test is performed as an inpatient

(b) only if this stress test is normal has ACS finally now been

excluded and the patient may go home

(c) local policy may be to arrange an outpatient stress test within

72 h of discharge instead. Make sure the general practitioner

(GP) is kept informed.

Non-cardiac chest pain

DIAGNOSIS

1 A stabbing, pleuritic, positional or palpation-induced pain is less character-
istic of ACS, but can not absolutely exclude it.

2 Thus non-cardiac chest pain is a diagnosis of exclusion, unless there are clear
features that indicate its origin such as immediate rib pain following a fall or
blow, or a sudden onset related to a sneeze or deep cough, or

3 Non-cardiac chest pain is diagnosed by finding definite features of an alter-
native diagnosis such as a PE, aortic dissection, pericarditis, pleurisy,
pneumothorax, etc. (see Table 2.1).
(i) Otherwise perform serial ECGs and troponins, and arrange a
stress test.

MANAGEMENT

1 Give every patient in whom the diagnosis is not immediately clear aspirin
150–300 mg orally unless contraindicated by known hypersensitivity.

2 Management will depend on which cause is suspected or found (see above or
following pages).

Pulmonary embolus

DIAGNOSIS

1 Venous thromboembolism (VTE) includes PE and deep venous thrombosis
(DVT).

2 Predisposing risk factors for VTE are best divided into acute provoking and
chronic predisposing, and apply to both PE and DVT (see Table 2.2).

Warning: never discharge any chest pain patient after a single normal

troponin test as a second paired test plus repeat ECG at 6–8 h post-arrival

are mandatory, followed by some form of stress test to definitely rule out

ACS.

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