Acute chest pain seen in the practice
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Suspected acute coronary syndrome (ongoing pain or pain within the last 72 hours)
In the practice
- 12-lead ECG as soon as possible, without delaying transfer; attach it to the letter or send it on.
- Ongoing pain, or pain within the last 12 hours with abnormal or unavailable ECG: call 15 (French emergency medical service). No laboratory tests in the community.
- Pain ended less than 12 hours ago with normal ECG, or last pain 12 to 72 hours ago: hospital assessment the same day. No laboratory tests in the community.
Do not order
- Troponin at a community laboratory when pain is ongoing or began less than 72 hours ago: refer urgently or the same day; HAS advises against outpatient troponin measurement, except in special cases [2,3]
- CK (and CK-MB): not indicated in coronary artery disease in ambulatory care and not reimbursable for this indication (NABM, procedures 1520 and 1526) [9]
- LDH: not indicated in coronary artery disease and not reimbursable for this indication (NABM, procedure 0521) [9]
- Myoglobin: reimbursable only in hospital, in the emergency pathway, within 6 hours of symptom onset (NABM, procedure 1575) [9]
- AST: outdated, non-specific marker, no longer indicated in the investigation of coronary artery disease; myoglobin is useless in ambulatory care [4]
Pain for more than 72 hours, possible uncomplicated ACS, asymptomatic patient
In the practice
- 12-lead ECG (compare with a previous tracing).
Laboratory tests
- Troponin
- Have the assay done as soon as possible, in a nearby laboratory, and collect the result the same day.
Also consider
Chest pain without suspected ACS: tests according to the suspected cause
Laboratory tests (depending on the hypothesis)
- D-dimer (if pulmonary embolism suspected with low or intermediate clinical probability)if neededSuspected pulmonary embolism in a stable patient, clinical probability not high (revised Geneva or Wells score): a negative result rules out embolism without imaging; age-adjusted threshold after 50 years (age × 10 µg/L) [10]. See the page “Deep vein thrombosis / pulmonary embolism”.
- CRPif needednon-French guidelinePositional pain, friction rub, diffuse ST elevation: raised CRP and leucocytes are common and help follow-up [11]. See the page “Acute pericarditis” (troponin required to rule out myopericarditis).
- FBCif needednon-French guidelinePositional pain, friction rub, diffuse ST elevation: raised CRP and leucocytes are common and help follow-up [11]. See the page “Acute pericarditis” (troponin required to rule out myopericarditis).
Also consider
- Pericarditis suspected? If pericarditis is suspected, see the "Acute pericarditis" page.
Do not order
Sources (12)
- Hoorweg BB, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart 2017;103:1727-1732.
- National Institute for Health and Care Excellence (NICE). Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Clinical guideline CG95, mars 2010, mise à jour 30 novembre 2016.
- Haute Autorité de santé. Guide du parcours de soins : maladie coronarienne stable. Juillet 2014 (actualisé en 2016).
- Haute Autorité de santé. Syndrome coronaire aigu : pas de marqueurs biologiques en médecine ambulatoire. Fiche Bon usage des technologies de santé, septembre 2010.
- Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826.
- National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand. Comprehensive Australian clinical guideline for diagnosing and managing acute coronary syndromes 2025. Heart Lung Circ. 2025;34(4):309-397.
- McConaghy JR, Sharma M, Patel H. Acute chest pain in adults: outpatient evaluation. Am Fam Physician. 2020;102(12):721-727.
- Bundesärztekammer, Kassenärztliche Bundesvereinigung, AWMF (Allemagne). Nationale VersorgungsLeitlinie Chronische KHK, version longue, version 7.0, 2024 (AWMF nvl-004).
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 0521 (LDH), 1520 (CPK), 1526 (CK-MB), 1575 (myoglobine) et 7335 (troponine).
- Sanchez O, Benhamou Y, Bertoletti L, et al. Recommandations de bonne pratique pour la prise en charge de la maladie veineuse thromboembolique chez l'adulte. Version courte. Rev Mal Respir. 2019;36(2):249-283.
- Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964.
- National Institute for Health and Care Excellence (NICE). Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Guideline NG158, mars 2020, mise à jour le 2 août 2023.