NICE clinical guidelines
Issued: March 2010

Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin

This is an extract from the guidance. The complete guidance is available at


This guidance partially updates NICE technology appraisal guidance 73 (published November 2003).

Recommendation in this guideline replaces recommendation 1.1 of NICE technology appraisal guidance 73. The NICE technology appraisal guidance and supporting documents are available.

Conditions causing chest pain or discomfort, such as an acute coronary syndrome or angina, have a potentially poor prognosis, emphasising the importance of prompt and accurate diagnosis. Treatments are available to improve symptoms and prolong life, hence the need for this guideline.

This guideline covers the assessment and diagnosis of people with recent onset chest pain or discomfort of suspected cardiac origin. In deciding whether chest pain may be cardiac and therefore whether this guideline is relevant, a number of factors should be taken into account. These include the person's history of chest pain, their cardiovascular risk factors, history of ischaemic heart disease and any previous treatment, and previous investigations for chest pain.

For pain that is suspected to be cardiac, there are two separate diagnostic pathways presented in the guideline. The first is for people with acute chest pain and a suspected acute coronary syndrome, and the second is for people with intermittent stable chest pain in whom stable angina is suspected. The guideline includes how to determine whether myocardial ischaemia is the cause of the chest pain and how to manage the chest pain while people are being assessed and investigated.

As far as possible, the recommendations in this guideline have been listed in the order in which they will be carried out and follow the diagnostic pathways. But, as there are many permutations at each decision point, it has been necessary to include frequent cross-referencing to avoid repeating recommendations several times.

The algorithms presented in appendix C show the two diagnostic pathways.

This guideline does not cover the diagnosis and management of chest pain that is unrelated to the heart (for example, traumatic chest wall injury, herpes zoster infection) when myocardial ischaemia has been excluded. The guideline also recognises that in people with a prior diagnosis of coronary artery disease, chest pain or discomfort is not necessarily cardiac.

The term 'chest pain' is used throughout the guideline to mean chest pain or discomfort.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.