Chest pain is the most common presenting symptom of coronary heart disease (CHD). The effective assessment and management of patients with chest pain is central to any strategy to reduce the burden of coronary disease. Furthermore the investigation of patients with chest pain absorbs a substantial proportion of the resources of cardiologists and their departments.

The simple facts of taking a history to elicit features of ischaemic pain, examining and then investigating using established procedures such as exercise testing, functional imaging, and angiography are well described in any textbook of medicine or cardiology. Indeed these will be well known to medical students. The challenge to senior clinicians is to synthesise a service that brings these principles to the patient in a timely, accessible, consistent, and cost conscious format to provide an effective service that takes patients within the population to the correct diagnosis and then onwards along their journey to evidence based treatments.

This article will therefore focus on how to organise services so that the full spectrum of patients with chest pain are assessed in the right way, in the right environment, and in the right time frame. Overall the evidence base for the way we organise services is limited and mainly observational, but the use of randomised trials is gaining a foothold. This article will take the subject of chest pain through assessment and investigation with a particular focus on CHD.

EPIDEMIOLOGY OF CHEST PAIN

Annually it is estimated that there are 634 000 primary care consultations for angina each year. The overall cost of caring for angina was calculated to be around 1% of the UK National Health Service (NHS) budget.¹ The burden of chest pain is far greater than the burden of angina. Nilsson and colleagues report from Sweden that 1.5% of primary care consultations are for chest pain, …