St Emlyn’s Lesson Plans

Chest pain: choosing the right diagnostic pathway

Discuss the initial chest-pain assessment and how to choose between ACS, PE and aortic investigation pathways.

New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 18 minutes in total.

When we meet: We will discuss abrupt pain radiating to the back and pleuritic pain in a younger adult, including what each investigation can establish.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Three pathway printouts and a whiteboard; no real patient data required.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.

Core preparation

NICE CG95: Recent-onset chest pain · About 7 minutes

Read only sections 1.2.4 (assessment in hospital) and 1.2.5 (biochemical markers). The facilitator will supply the current local troponin pathway for comparison during the session; you do not need to find it beforehand.

https://www.nice.org.uk/guidance/CG95/chapter/recommendations

NICE NG158: Venous thromboembolic diseases · About 8 minutes

Read NG158’s PERC, two-level Wells and D-dimer recommendations. Note which patients are eligible for each step.

https://www.nice.org.uk/guidance/ng158/chapter/Recommendations

Think about (allow 3 minutes): What important cause of chest pain could remain after a reassuring ECG and troponin?

Picture the scene

Near the end of a shift, you are asked to assess “one quick chest pain”. What do you need to know before deciding which tests will help?

By the end of the session

Recognise features needing urgent senior assessment before routine testing.
Choose an ACS, PE or aortic investigation pathway based on the presentation.
Explain why a reassuring result on one pathway does not exclude another cause.

After the session

Explain to a colleague why you selected a test before ordering it.
Check the actual assay timing and discharge criteria in your department’s chest-pain pathway.

Optional further learning

You do not need to complete this before attending. The listening time is additional to the core preparation above.

Optional listening · 19 min 30 sec

St Emlyn’s Podcast: Ep 299 - Which patients with chest pain need a troponin?

Explore how symptoms and clinical judgement influence the decision to request troponin.

Listen to the episode

Search for this episode by title in MedPod Learn if you want to record your listening there.

Identify one apparently reassuring feature that cannot safely exclude MI. Explain how a credible alternative diagnosis changes your assessment. The numerical estimates concern selected suspected-ACS populations; use the current local ECG/troponin pathway. If you have heard this episode before, bring your previous reflection.

https://www.stemlynspodcast.org/e/ep-299-which-patients-with-chest-pain-need-a-troponin/

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 18 minutes in total.

Before learners arrive

Bring current local ACS/troponin, PE and aortic-dissection pathways on paper or as accessible links. The learner preparation does not require intranet access.
Confirm troponin assay timing and who can authorise urgent aortic imaging.
Check senior sign-off arrangements for chest-pain discharge.

Equipment: Three pathway printouts and a whiteboard; no real patient data required.

Setup: Give pairs one of the two cases. Each pair explains which pathway they would use, what the first test can answer and what they would do with either result. Compare the decisions as a group.

If the preparation has not been completed

Replace the differential and test-selection opening (13 minutes). Use eight minutes to find the entry criteria in the local ACS, PE and aortic pathways supplied by the facilitator. Each pair then takes five minutes to explain what its first investigation can and cannot answer. If intranet access is unavailable, use the printed pathways. For the 30-minute version, use the first eight minutes for a five-minute pathway read and three-minute comparison, replacing the differential and tests-and-questions activities.

Suggested session plan

0–5 min — Open the differential. Ask what a “quick chest pain” label might hide.
5–13 min — Match tests to questions. Groups state what ECG, troponin and D-dimer can and cannot answer.
13–35 min — Two cases. Require a reason before a test and a next action after a result.
35–40 min — Consolidate. Ask each group to explain one misleading reassurance.
40–45 min — Choose a follow-up action. Identify a pathway detail to check before the next shift.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Abrupt pain through to the back

A 60-year-old with hypertension develops abrupt severe chest pain radiating to the back. Their current BP is 180/100 and examination has no obvious focal abnormality.

Add this information as the discussion develops:

The first ECG has no acute ischaemic changes and the troponin is low.

Ask the group:

What diagnosis still needs urgent consideration?
What information changes the imaging decision?
Which reassuring tests do not answer that question?

Discussion notes

Points to draw out:

Consider acute aortic syndrome and obtain prompt senior assessment, monitoring and the current RCEM/RCR imaging pathway.
Assess the onset, pain features, vascular/neurological findings and risk context; absence of a pulse deficit does not exclude disease.
An ECG, troponin, chest radiograph or bedside echo cannot independently rule out dissection. Definitive imaging decisions follow clinical assessment and the aortic pathway.

Common misconceptions:

Treating a negative ACS work-up as exclusion of all dangerous chest pain.
Starting a routine antithrombotic pathway without considering aortic or bleeding pathology.

For a more experienced group: Discuss how instability affects location of care, imaging and specialist coordination.

Pleuritic pain in a younger adult

A 35-year-old has pleuritic pain and exertional breathlessness, with oxygen saturation 95% on air.

Add this information as the discussion develops:

Further history reveals recent immobilisation. A colleague suggests “PERC or Wells—whichever is quicker”.

Ask the group:

What establishes the initial clinical suspicion?
When is PERC appropriate and when should another pathway be used?
What will a positive D-dimer establish?

Discussion notes

Points to draw out:

Assess the whole presentation, alternative diagnoses and relevant risk factors before choosing a decision tool.
PERC is considered only when overall suspicion is low and another diagnosis is feasible; it is not interchangeable with Wells in every patient.
If PE is suspected, use the two-level Wells pathway. D-dimer has a role in the appropriate probability group; a positive result is not a diagnosis.
NG158 excludes pregnancy: use the appropriate pregnancy-specific pathway when relevant.

Common misconceptions:

Calling PE impossible because the patient is young or saturations are normal.
Ordering D-dimer indiscriminately and then treating the result as certainty.

For a more experienced group: Compare the harms of unnecessary testing with the risk of missing disease; ask what additional history most changes the plan.

Important clinical points

A normal initial ECG does not exclude ACS; do not restrict troponin testing to patients with a normal ECG.
Use the locally validated high-sensitivity troponin pathway, accounting for symptom timing and clinical concern.
A reassuring bedside ultrasound does not exclude aortic dissection or PE; obtain senior input when serious pathology remains plausible.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Which reassuring results fail to exclude aortic dissection?
Why can PERC and Wells not simply be substituted for one another?
What needs to be true before a negative troponin supports discharge?

Key teaching points:

Use the history and examination to decide which clinical question needs answering.
Reassuring results on one pathway do not exclude every serious cause of chest pain.
Consider the timing, pre-test probability and remaining clinical concern when interpreting results.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

No investigation makes risk zero. Discharge requires an explanation, a proportionate assessment and follow-up/return advice appropriate to the patient.

If the discussion drifts

What clinical question will this test answer, and what will we do with either result?

For a more experienced group

Add a recurrent-pain scenario with an early negative troponin and ask the group to use the exact local assay pathway rather than a generic interval.

A 30-minute version

30 minutes: differential 3; tests and questions 5; aortic case 9; PE case 9; reflection 4. Omit the longer group teach-back.

Evidence and guidance

NICE CG95: Recent-onset chest pain — Acute cardiac assessment; use the locally validated high-sensitivity troponin pathway.https://www.nice.org.uk/guidance/cg95
NICE NG158: Venous thromboembolic diseases — Updated 2023: PERC in selected low-suspicion patients; Wells/D-dimer/imaging pathways. Does not cover pregnancy.https://www.nice.org.uk/guidance/ng158/chapter/Recommendations
RCEM/RCR: Thoracic aortic dissection — June 2026 guideline; clinical suspicion, definitive imaging and escalation.https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf