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The approach to patients with possible cardiac chest pain

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Chest pain is a confronting symptom for patients and clinicians alike. Some patients presenting with chest pain will have serious acute illness with a high short-term risk of mortality, but this will be excluded in most patients. Chest pain is one of the most common causes of attendance at hospital emergency departments (EDs) and a frequent cause of presentations to general practice.1 Missed diagnosis, with associated adverse outcomes, can occur when chest pain assessment is based on clinical features alone.2

Regardless of the clinical setting, a stepwise approach should be applied to patients with chest pain (Box 1). In the absence of trauma, the primary focus should be exclusion of four potentially fatal conditions: acute coronary syndrome (ACS; encompassing acute myocardial infarction and unstable angina), pulmonary embolism, aortic dissection and spontaneous pneumothorax. ACS is by far the most common of these. All these conditions may present without immediately obvious physical signs, but the latter three may be accurately excluded by rapid diagnostic testing (predominantly medical imaging). However, ACS is more challenging as it cannot be readily excluded with an acceptable level of accuracy on initial clinical evaluation or with a single investigation.…