Chest pain in primary care

A 55-year-old man complains of palpitations. Examination of his cardiorespiratory system is unremarkable. A resting ECG is therefore ordered prior to arranging a 24-hour tape.

• Wolff-Parkinson White syndrome

• Right bundle branch block

• Left bundle branch block

• Recent myocardial infarction

You are reviewing a 50-year-old woman who is complaining of exertional chest pain for the past six months. The pain typically eases when she rests and she has had no episodes of pain lasting more than three minutes. Clinical examination and resting ECG are normal. You arrange fasting blood tests. Following NICE guidelines, what is the most appropriate next step?

• Give a trial of GTN spray

• Arrange no further diagnostic tests and treat her as having angina

• Calculate her estimated risk of having coronary artery disease

• Refer for a coronary angiography

A 67-year-old woman is reviewed in the afternoon clinic. She describes a 20 minute episode heavy central chest pain shortly after getting up from bed this morning, about 7 hours ago. This has not happened before and she has been pain free since the morning. Clinical examination is normal but the ECG shows T wave inversion in the inferior leads. What is the most appropriate management

• Refer for an exercise tolerance test

• Give aspirin + arrange for same-day hospital assessment

• Start aspirin + check troponin I level

• Give aspirin + arrange an emergency admission (immediate

  ambulance)

A patient with known heart failure is unable to carry out any physical activity without discomfort. Symptoms of heart failure are present even at rest with increased discomfort with any physical activity. What New York Heart Association class best describes the severity of their disease?

• NYHA Class 1

• NYHA Class 2

• NYHA Class 3

• NYHA Class 4

A 42-year-old overweight man presents with a two day history of anterior chest pain that is worse on deep inspiration and lying down

• Myocardial infarction

• Gastro-oesophageal reflux disease

• Pericarditis

• Myocarditis

A 67-year-old female with a history of chronic lymphocytic leukaemia presents with a 3 day history of burning pain in the right lower chest wall.

• Pulmonary embolism

• Dissecting aortic aneurysm

• Gastroesophageal reflux disease

• Shingles

A 25-year-old man with a history of Marfan's disease presents with sudden onset shortness of breath and pleuritic chest pain

• Pleurisy

• Myocardial infarction

• Pneumothorax

• Pulmonary embolism

A patient attends the local walk-in centre with central crushing chest pain. The nurse phones 999 and performs an ECG which shows ST elevation in leads II, III and aVF. His blood pressure is 130/70 mmHg, pulse 90 / min and oxygen saturations of 96%. What is the most appropriate management whilst waiting for the ambulance?

• Aspirin 300mg + clopidogrel 300mg + sublingual glyceryl trinitrate

• Oxygen + aspirin 300mg + clopidogrel 300mg + sublingual glyceryl

  trinitrate

• Aspirin 300mg + lansoprazole 30mg + sublingual glyceryl trinitrate

• Oxygen + aspirin 300mg + sublingual glyceryl trinitrate