Chest Pain: Low Risk ‘Rule-Out’ Pathways

Authors: Stephen W Goodacre, Jason M Kendall / Editors: Michael Perry, Tajek B Hassan / Reviewer: Philip Delbridge / Code: A1Published: 28/02/2022

Before commencing this session you should:

  • Understand the pathophysiology of acute coronary syndrome
  • Be able to interpret a 12-lead ECG
  • Understand how diagnostic tests work, in terms of sensitivity, specificity and likelihood ratios
  • Complete the Learning Zone session on Chest Pain Syndromes


This session addresses the clinical assessment and management of patients with low risk chest pain, specifically the identification of patients with acute coronary syndrome.

After completing this session you will be able to:

  • Define low risk chest pain, describe patient characteristics and outline the diagnostic challenge
  • Identify clinical features that are useful for ruling in, or ruling out, a diagnosis of acute myocardial infarction (AMI)
  • Outline the diagnostic value of electrocardiography, biochemical cardiac markers and provocative exercise testing
  • Describe other common diagnoses in a patient with low risk chest pain
  • Determine which patients require further investigation to rule in, or rule out, coronary artery disease once an Acute Coronary Syndrome has been excluded


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  10. Goodacre S, Nicholl J, Dixon S, Cross E, et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004;328:254-7.
  11. Morrow DA, Cannon CP, Jesse RL, Newby LK, et al. National Academy of Clinical Biochemistry. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Clin Chem. 2007 Apr;53(4):552-74.
  12. National Institute of Health and Clinical Excellence. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. NICE Guideline [CG95], London, March 2010. 

Further Reading

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