Chest pain is common in general practice (about 1.5% of all presentations), and can make both patients and doctors feel anxious. The priority for the GP is not to miss any life-threatening causes, such as MI. Only about 8% of all the chest pain that a GP sees is caused by cardiac disease. Most chest pain in general practice has a more benign origin, such as musculoskeletal problems, gastro-oesophageal reflux or panic disorder (see Figure 34a). The key to managing chest pain lies in taking a careful history. So, unless the patient is acutely unwell, take your time getting the story straight.

Taking a History

• Start with open questions to let the patient describe the pain in their own words (‘Tell me more about this chest pain you’ve been getting’).
  
• Encourage the patient to open up more (‘And was there anything else about it …?).
  
• Find out if they have any particular ideas or worries about the pain.
  
• Use more direct questioning later, to establish whether the patient has any features of cardiac ischaemia. You could use a mnemonic such as SOCRATES to remember what to ask (see Table 34.1).
  
• Does the patient have a past history of a heart attack or a stroke or any clotting disorders?
  
• Is there any family history of cardiovascular disease?
  
• Any patient with chest pain should also be asked about the risk factors for cardiovascular disease: smoking, diabetes, hypertension, hyperlipidaemia, obesity, lack of exercise and stress.
  
• The patient’s medication may give you a clue as to their medical problems. Patients often forget to mention they have hypertension, but may be able to tell you that they take a daily ACE inhibitor.
  
• Differentiate stable from unstable angina. Stable angina is reliably provoked by (for instance) climbing two flights of stairs. Unstable angina comes without apparent provocation and requires urgent hospital assessment.

Examination

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