Chest Pain

Last updated 31 May 2026 · Cardiology / General Practice

📋 Key Information Summary

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Chest pain is the single most common presenting complaint in Australian emergency departments, accounting for >700,000 presentations annually; the primary goal is rapid identification of life-threatening causes while avoiding unnecessary admissions.
The HEART pathway and EDACS (Emergency Department Assessment of Chest Pain) are validated for Australian practice and can safely discharge low-risk patients within 2–3 hours using serial troponins.
Acute coronary syndromes (ACS) encompass STEMI, NSTEMI, and unstable angina — always consider ACS first because missed MI carries a 2.5-fold increase in 30-day mortality.
Red-flag features requiring immediate action: crushing central chest pain radiating to the left arm or jaw, diaphoresis, haemodynamic instability, new ST-elevation ≥1 mm in two contiguous leads, or new left bundle branch block.
High-sensitivity troponin (hs-cTn) with a 0/1-hour or 0/2-hour algorithm is the standard of care in Australian EDs; troponin I or T assays must be interpreted with sex-specific 99th-percentile upper reference limits.
STEMI management: door-to-balloon PCI ≤90 minutes if PCI-capable; if not, fibrinolysis (tenecteplase) within 30 minutes of first medical contact followed by transfer for angiography within 2–24 hours.
NSTEMI / unstable angina risk-stratify with GRACE or TIMI score; dual antiplatelet therapy (aspirin + ticagrelor or prasugrel/clopidogrel), anticoagulation (heparin), and timely invasive strategy per GRACE risk.
GTN (sublingual spray 400 µg) and IV morphine remain first-line symptom relief for ischaemic chest pain; routine oxygen is NOT recommended unless SpO₂ <94%.
Non-cardiac causes account for 50–70 % of ED chest-pain presentations: musculoskeletal (costochondritis, Tietze), gastrointestinal (GORD, oesophageal spasm), anxiety/panic, and pulmonary embolism must be systematically excluded.
Stress testing (exercise ECG, stress echo, or CT coronary angiography) is recommended for intermediate-risk patients within 72 hours of ED discharge and is funded via MBS item numbers 11204–11224.
Aboriginal and Torres Strait Islander Australians have 1.7× the rate of ACS hospitalisation and higher out-of-hospital cardiac death; culturally safe assessment, outreach cardiology, and ACCHS-facilitated follow-up are essential.
Women, older adults, and people with diabetes frequently present with atypical symptoms (dyspnoea, fatigue, nausea, back pain) rather than classic chest pain — maintain a low threshold for investigation.
All suspected ACS patients should receive aspirin 300 mg (chewed) immediately unless contraindicated; PBS authority-required ticagrelor or clopidogrel are added per interventional cardiologist or local protocol.

Introduction & Australian Epidemiology

Chest pain is one of the most frequent reasons for emergency department (ED) attendance and general practice consultation in Australia. It encompasses a broad differential diagnosis ranging from immediately life-threatening conditions (acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, oesophageal rupture) to benign and self-limiting disorders (musculoskeletal strain, gastro-oesophageal reflux, anxiety). A structured, evidence-based diagnostic approach is essential to minimise missed acute coronary events while avoiding unnecessary hospital admissions and invasive investigations.

Australian burden of disease: According to the Australian Institute of Health and Welfare (AIHW, 2023), ischaemic heart disease remains the leading single cause of death in Australia, responsible for approximately 17,500 deaths per year. Acute coronary syndromes account for roughly 70,000 hospitalisations annually. Chest pain presentations to EDs exceed 700,000 per year, yet only 10–15 % of these patients receive a final diagnosis of ACS. This low diagnostic yield underscores the importance of efficient risk stratification pathways that are safe, cost-effective, and feasible in the Australian healthcare context.

Key national datasets:

AIHW Cardiovascular Disease Statistics — hospital separations, mortality, and prevalence data.
National Heart Foundation of Australia / Cardiac Society of Australia and New Zealand (CSANZ) clinical guidelines.
ACSQHC Acute Coronary Syndromes Clinical Care Standard (2019, updated 2023).
MyHeartMap and Australian Stroke and Heart Atlas for geographic variation.

Sex and age differences: Women are more likely to present with atypical symptoms such as dyspnoea, fatigue, nausea, and upper-back or jaw pain. Older adults (≥65 years) and those with diabetes mellitus may also lack classic ischaemic features, leading to delayed diagnosis. Indigenous Australians experience ACS at younger ages and with higher case-fatality rates than non-Indigenous Australians, highlighting the need for targeted screening and culturally safe care pathways.

Chest Pain Diagnostic Model

A systematic approach to the undifferentiated chest-pain patient integrates clinical history, electrocardiography, and serial high-sensitivity cardiac troponin (hs-cTn) measurement. Two validated decision aids are widely used in Australian emergency departments:

HEART Pathway

The HEART score allocates points across five domains (History, ECG, Age, Risk factors, Troponin). A score of 0–3 identifies low-risk patients suitable for early outpatient investigation; 4–6 denotes moderate risk warranting observation and serial troponins; 7–10 is high risk and mandates inpatient cardiology assessment and likely invasive strategy.

Domain	0 points	1 point	2 points
History	Slightly suspicious	Moderately suspicious	Highly suspicious
ECG	Normal	Non-specific repolarisation disturbance	Significant ST deviation
Age	<45 years	45–64 years	≥65 years
Risk factors	No known risk factors	1–2 risk factors	≥3 risk factors or history of atherosclerotic disease
Troponin	≤ normal limit	1–3× normal limit	>3× normal limit

EDACS (Emergency Department Assessment of Chest Pain Score)

EDACS was developed and validated in New Zealand and Australian cohorts (Than et al., 2014). Combined with serial hs-cTn at 0 and 2 hours, EDACS-low-risk patients can be safely discharged for outpatient stress testing within 72 hours. This pathway reduces ED length of stay by a median of 3.5 hours compared with traditional troponin-only strategies.

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Australian recommendation: The CSANZ and National Heart Foundation recommend the use of either the HEART pathway or the 2-hour accelerated diagnostic protocol (ADP) incorporating EDACS, TIMI, or HEART score with 0/2-hour hs-cTn for safe early discharge of low-risk chest pain. MBS item 66846 covers ED presentations.

Differential Diagnosis Framework

The clinician should systematically categorise chest pain into four urgency tiers:

Life-threatening

Immediate Action

ACS / STEMI, aortic dissection, pulmonary embolism, tension pneumothorax, oesophageal rupture (Boerhaave syndrome), cardiac tamponade.

Setting: Resuscitation bay — activate Code STEMI or Rapid Response

Urgent

Assess & Investigate

NSTEMI, unstable angina, pericarditis / myocarditis, hypertrophic cardiomyopathy, symptomatic arrhythmia, pleuritis, complicated GORD.

Setting: ED monitored bed, cardiology consult

Semi-urgent

Outpatient Follow-up

Stable angina, GORD, oesophageal spasm, costochondritis, anxiety / panic disorder, herpes zoster.

Setting: Discharge with GP follow-up ± stress test within 72 h

Acute Coronary Syndromes (STEMI, NSTEMI, Unstable Angina)

Acute coronary syndromes result from acute disruption of an atherosclerotic coronary plaque leading to thrombus formation, myocardial ischaemia, and variable degrees of myocardial necrosis. The three ACS subtypes are defined by ECG findings and cardiac biomarker results:

ACS Subtype	ECG Finding	Troponin	Pathology
STEMI	ST elevation ≥1 mm in ≥2 contiguous leads (≥2 mm in V1–V3) or new LBBB	Elevated (but treat on ECG — do NOT wait)	Complete coronary occlusion → transmural infarction
NSTEMI	ST depression, T-wave inversion, or non-specific changes	Elevated above 99th percentile with rising/falling pattern	Subtotal occlusion or microvascular occlusion → subendocardial necrosis
Unstable angina	May be normal or show ischaemic changes	Normal (no necrosis)	Plaque disruption without sufficient necrosis to raise biomarkers

STEMI — Emergency Management

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Time-critical: For STEMI, the ACSQHC Clinical Care Standard mandates first medical contact (FMC) to reperfusion ≤120 minutes (PCI-capable centre: door-to-balloon ≤90 min; non-PCI centre: FMC-to-needle ≤30 min with subsequent transfer). Activate the Code STEMI pathway immediately upon ECG interpretation.

Reperfusion strategy:

Primary PCI (percutaneous coronary intervention): Preferred when available within 120 minutes of FMC. All Australian metropolitan tertiary hospitals and many regional centres (e.g., Geelong, Wollongong, Gold Coast) have 24/7 catheterisation laboratory capability.
Fibrinolysis: Tenecteplase (weight-adjusted single IV bolus) is the recommended agent when PCI is not accessible within 120 minutes. Administer within 30 minutes of arrival. Arrange urgent transfer for rescue PCI if fibrinolysis fails (persistent ST elevation at 60–90 minutes) or routine angiography within 2–24 hours if successful. PBS Authority Required for tenecteplase.

NSTEMI / Unstable Angina — Risk Stratification & Management

Patients with NSTEMI or unstable angina should be risk-stratified using the GRACE 2.0 score (Global Registry of Acute Coronary Events) to guide the timing of invasive management:

GRACE score >140 (very high risk): Immediate invasive strategy (angiography within 2 hours). Features: haemodynamic instability, ongoing ischaemia, life-threatening arrhythmia, mechanical complications.
GRACE score 109–140 (high risk): Early invasive strategy (angiography within 24 hours).
GRACE score <109 (low/intermediate risk): Invasive strategy within 72 hours or conservative strategy with ischaemia-guided approach based on clinical judgement.

Pharmacotherapy for ACS — Drug Cards

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Aspirin

Aspro Clear® · Cartia® · Antiplatelet (COX-1 inhibitor)

Adult dose (acute) 300 mg PO chewed immediately, then 100 mg PO daily

Paediatric dose Not applicable for ACS in children

Renal adjustment None required

Hepatic adjustment Use with caution; avoid in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Ticagrelor

Brilinta® · P2Y12 receptor antagonist

Adult dose Loading dose 180 mg PO, then 90 mg PO BD for 12 months post-ACS

Renal adjustment No dose adjustment; caution in severe renal impairment

Hepatic adjustment Contraindicated in severe hepatic impairment

PBS status ⚠ PBS Authority Required

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Clopidogrel

Plavix® · Iscover® · P2Y12 receptor antagonist

Adult dose Loading dose 300–600 mg PO, then 75 mg PO daily

Renal adjustment No dose adjustment

Hepatic adjustment Use with caution in hepatic impairment

PBS status ✔ PBS General Benefit

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Enoxaparin

Clexane® · Low-molecular-weight heparin

Adult dose (NSTEMI/UA) 1 mg/kg SC every 12 hours (reduce to 1 mg/kg SC OD if eGFR <30 mL/min)

Renal adjustment eGFR <30: 1 mg/kg SC OD; consider anti-Xa monitoring

PBS status ✔ PBS General Benefit

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Tenecteplase

Metalyse® · Fibrinolytic (tPA analogue)

Adult dose Weight-adjusted IV bolus (30–50 mg based on weight ≥60–≥90 kg); single dose

Indication STEMI when primary PCI not available within 120 min of FMC

Renal adjustment Not required

PBS status ⚠ PBS Authority Required

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Glyceryl trinitrate (GTN)

Anginine® · Lycinate® · Nitrate vasodilator

Adult dose (acute) 400 µg sublingual spray or 0.5 mg tablet every 5 min (max 3 doses); then IV infusion 5–200 µg/min titrated to pain and BP

Contraindications SBP <90 mmHg, RV infarction, PDE-5 inhibitor use within 24–48 hours

PBS status ✔ PBS General Benefit

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Safety: Do NOT administer GTN to patients with suspected right ventricular infarction (inferior STEMI with right-sided leads showing ST elevation in V4R) — this may cause catastrophic hypotension. Always check blood pressure before each GTN dose.

Secondary Prevention Post-ACS

All ACS patients should be discharged on:

Dual antiplatelet therapy (DAPT) — aspirin 100 mg daily + ticagrelor 90 mg BD (or clopidogrel 75 mg daily) for ≥12 months.
High-intensity statin — atorvastatin 80 mg PO nocte (PBS General Benefit) or rosuvastatin 20–40 mg PO daily.
Beta-blocker (bisoprolol 1.25–10 mg or metoprolol succinate 23.75–190 mg) if LVEF ≤40 % or ongoing ischaemia.
ACE inhibitor (ramipril 2.5–10 mg) or ARB (valsartan 40–160 mg BD) if LVEF ≤40 %, anterior MI, diabetes, or hypertension.
Mineralocorticoid receptor antagonist (eplerenone 25–50 mg) if LVEF ≤40 % with heart failure symptoms.
Smoking cessation support (PBS-listed nicotine replacement or varenicline) and cardiac rehabilitation referral (MBS item 93050–93053).

Red Flags & Investigations

Red-Flag Features Demanding Immediate Escalation

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Crushing, pressure-like, or tight central chest pain radiating to the left arm, jaw, or epigastrium.
Associated diaphoresis, nausea, or dyspnoea.
Haemodynamic instability: SBP <90 mmHg, HR >100 bpm, signs of cardiogenic shock.
ECG: ST elevation ≥1 mm (≥2 mm V1–V3) in ≥2 contiguous leads, new LBBB, Wellens syndrome (deep symmetric T-wave inversion in V2–V3), de Winter T-waves.
New-onset heart failure: pulmonary oedema, raised JVP, S3 gallop.
Syncope or sustained ventricular arrhythmia in the setting of chest pain.
Tear-type chest pain radiating to the back with pulse differential — consider aortic dissection (call vascular surgery and perform CT aortogram).

ECG Interpretation — Key Patterns

A 12-lead ECG must be obtained within 10 minutes of first medical contact for all patients presenting with chest pain.

ECG Pattern	Significance	Action
ST elevation ≥1 mm in ≥2 contiguous leads	STEMI	Activate Code STEMI; immediate reperfusion
New left bundle branch block (LBBB)	Suspected STEMI equivalent	Treat as STEMI until proven otherwise
ST depression ≥0.5 mm, T-wave inversion	NSTEMI / ischaemia	Serial troponins, cardiology consult
Deep symmetric T-wave inversion V2–V3 (Wellens)	Critical LAD stenosis	Urgent angiography; avoid stress testing
De Winter T-waves (upsloping ST depression + tall T-waves precordial)	LAD occlusion equivalent	Treat as STEMI
Diffuse concave ST elevation, PR depression	Pericarditis	NSAIDs, colchicine; echo for effusion
Low voltage, electrical alternans	Large pericardial effusion / tamponade	Urgent echocardiography; consider pericardiocentesis

High-Sensitivity Troponin (hs-cTn)

High-sensitivity cardiac troponin assays (hs-cTnT and hs-cTnI) are the standard of care in all Australian hospital laboratories. Key principles:

Sex-specific 99th percentile upper reference limits (URL): hs-cTnT: 15.5 ng/L (female), 21.7 ng/L (male); hs-cTnI (Abbott Architect): 16 ng/L (female), 34 ng/L (male).
0/1-hour algorithm (ESC-recommended): If baseline hs-cTn is below the rule-out threshold and the 1-hour delta is minimal → low risk; if above the rule-in threshold or significant delta → high risk; intermediate values require 3-hour retest.
0/2-hour algorithm (ADAPT-ADP / EDACS protocol): Used widely in Australian EDs; validated by Than et al. in Australasian cohorts.
Chronic troponin elevation: Common in CKD (eGFR <30), heart failure, and LVH. Serial delta change (rise and/or fall) is essential to distinguish acute from chronic elevation.

Stress Testing & CT Coronary Angiography

MBS 11204

Exercise ECG (stress ECG)

First-line for intermediate-risk patients with interpretable baseline ECG and ability to exercise. Sensitivity 68 %, specificity 77 %. Available in most metropolitan and regional centres.

MBS 11214

Stress echocardiography

Higher sensitivity (80–85 %) than exercise ECG; dobutamine or exercise stress. Preferred in women and patients with LBBB or ventricular pacing. Available in metropolitan and large regional centres.

MBS 57360

CT coronary angiography (CTCA)

High sensitivity (95–99 %) and NPV for anatomically significant CAD. Increasingly used in Australian EDs for low-to-intermediate risk chest pain (SCOT-HEART trial). Requires iodinated contrast and IV access. Available in major metropolitan hospitals.

Referral needed

Myocardial perfusion imaging (SPECT MPI)

Nuclear medicine investigation; sensitivity 85–90 %. Requires referral to nuclear medicine. Available in most tertiary centres. MBS item 61315.

Cardiologist

Invasive coronary angiography

Gold standard for defining coronary anatomy. Indicated for high-risk ACS, failed medical therapy, or positive non-invasive testing. Requires catheterisation laboratory (PCI-capable centre).

Oesophageal & MSK Causes of Chest Pain

Non-cardiac chest pain accounts for 50–70 % of all chest-pain presentations in Australian EDs. Musculoskeletal and gastrointestinal aetiologies are the two most common categories. Systematic evaluation prevents both missed cardiac diagnoses and unnecessary invasive investigation.

Gastro-Oesophageal Causes

Condition	Clinical Features	Diagnosis	Management
Gastro-oesophageal reflux disease (GORD)	Burning retrosternal pain worse after meals, lying flat, or bending; relieved by antacids; associated with regurgitation	Clinical diagnosis; 24-h pH monitoring if atypical; upper endoscopy if alarm features	PPI (esomeprazole 20–40 mg PO daily); lifestyle modification; PBS General Benefit
Oesophageal spasm	Severe, squeezing central chest pain mimicking angina; may be triggered by hot/cold food or stress	High-resolution oesophageal manometry (referral)	GTN sublingual (empirical), CCBs (diltiazem 60 mg TDS PO), PPI
Boerhaave syndrome (oesophageal rupture)	Severe chest pain after forceful vomiting; subcutaneous emphysema; Mackler's triad (vomiting, chest pain, subcutaneous emphysema)	CT chest with oral contrast (gold standard); water-soluble contrast swallow	Surgical emergency — immediate cardiothoracic/upper-GI surgical consultation; IV antibiotics, NBM

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Proton-pump inhibitor (PPI) test: An empirical 2-week trial of high-dose PPI (e.g., esomeprazole 40 mg BD) can serve as both diagnostic and therapeutic for GORD-related chest pain. A positive response supports GORD as the cause. This approach is endorsed by RACGP guidelines.

Musculoskeletal Causes

Musculoskeletal chest pain is the most common non-cardiac aetiology, affecting up to 30–50 % of ED chest-pain patients. It is characterised by:

Reproducible chest-wall tenderness on palpation (high negative predictive value for ACS).
Pain exacerbated by movement, deep breathing, or specific postures.
No associated dyspnoea, diaphoresis, or haemodynamic compromise.

Condition	Features	Management
Costochondritis	Pain at costochondral junctions (usually 2nd–5th ribs); localised tenderness without swelling	NSAIDs (ibuprofen 400 mg PO TDS with food or naproxen 250–500 mg PO BD); heat packs; reassurance
Tietze syndrome	As costochondritis but with visible swelling at the costochondral junction	NSAIDs; local corticosteroid injection if refractory
Muscle strain (intercostal, pectoralis)	History of physical exertion or repetitive movement; pain with resisted muscle contraction	Rest, simple analgesia (paracetamol 1 g QID PRN), graduated return to activity
Rib fracture	History of trauma; focal bony tenderness; pain with inspiration	Analgesia (stepwise: paracetamol → NSAIDs → opioids); incentive spirometry; chest X-ray (may miss non-displaced fractures)
Cervical / thoracic radiculopathy	Dermatomal pain; paraesthesia; reproduced by neck/spinal movements	Physiotherapy, simple analgesia; MRI spine if persistent (MBS item 63210)

Other Important Non-Cardiac Causes

Pulmonary embolism: Pleuritic chest pain, tachycardia, hypoxia; Wells score and D-dimer screening (MBS item 65120); CT pulmonary angiography (CTPA) if indicated. Refer to PE article.
Pneumothorax: Sudden-onset pleuritic pain with dyspnoea; reduced breath sounds; CXR or POCUS. Refer to pneumothorax article.
Herpes zoster: Dermatomal burning or lancinating pain preceding vesicular rash; may mimic cardiac pain if left-sided. Treat with valaciclovir 1 g PO TDS for 7 days (PBS General Benefit).
Anxiety / panic disorder: Often associated with hyperventilation, perioral tingling, and palpitations. Diagnosis of exclusion. Consider referral to GP Mental Health Treatment Plan (MBS item 80110).

Special Populations

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Pregnancy

Chest pain evaluation

Pregnancy-related causes include pre-eclampsia, peripartum cardiomyopathy, aortic dissection (Marfan syndrome), and amniotic fluid embolism. ECG and troponin can be interpreted normally; exercise stress testing is safe in uncomplicated pregnancies.

Aspirin

Low-dose aspirin (100–150 mg) is used for pre-eclampsia prophylaxis. Doses ≥300 mg/day for ACS should be used with caution and obstetric input.

Statin contraindication

Statins are contraindicated in pregnancy (Category X). Discontinue immediately if ACS occurs in pregnancy.

Radiation exposure

CT coronary angiography and SPECT MPI carry fetal radiation exposure; use shielding and alternative modalities (stress echo) where possible.

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Paediatrics

Common causes

Musculoskeletal (costochondritis, precordial catch syndrome), anxiety, asthma, and viral myopericarditis are the most common causes in children. ACS is exceptionally rare but consider Kawasaki disease, anomalous coronary arteries, and hypertrophic cardiomyopathy.

Troponin interpretation

Paediatric reference ranges differ from adults; use age- and assay-specific 99th percentile. Healthy neonates may have elevated troponin in the first 72 hours of life.

Drug doses

Antiplatelet and anticoagulant doses are weight-based; consult Children's Health Queensland or RCH Melbourne dosing guidelines. Aspirin (3–5 mg/kg/day) is used in Kawasaki disease.

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Older Adults (≥65 years)

Atypical presentations

Dyspnoea, confusion, syncope, fatigue, and nausea may be the predominant features. Up to 30 % of older adults with ACS lack chest pain.

Polypharmacy considerations

DAPT bleeding risk increases with age (HAS-BLED score). Proton-pump inhibitor co-prescription (e.g., pantoprazole 20 mg PO daily) is recommended for gastroprotection.

Troponin interpretation

Chronic troponin elevation is common due to LVH, CKD, and HF. Serial delta change is essential. eGFR-guided enoxaparin dosing is critical.

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Renal Impairment

Troponin elevation

Baseline troponin is commonly elevated in CKD stages 4–5. Use delta change (rise/fall pattern) for diagnosis of acute myocardial infarction. hs-cTnI may be preferred over hs-cTnT in dialysis-dependent patients.

Enoxaparin

eGFR <30 mL/min: reduce to 1 mg/kg SC OD. Consider anti-Xa level monitoring (target 0.5–1.0 IU/mL for treatment).

Contrast nephropathy

Pre- and post-contrast IV saline hydration for patients with eGFR <30 undergoing CT coronary angiography or invasive angiography. Discuss risk-benefit with cardiology.

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Hepatic Impairment

Ticagrelor

Contraindicated in severe hepatic impairment (Child-Pugh C). Use clopidogrel as the P2Y12 inhibitor alternative.

Statins

Use with caution in active liver disease; avoid in decompensated cirrhosis. Monitor LFTs at baseline, 3 months, and 12 months.

Coagulopathy

Baseline INR may be elevated; interpret anticoagulation response carefully. Discuss with hepatology and cardiology before initiating anticoagulation.

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Immunocompromised

Expanded differential

CMV myocarditis, cryptococcal pericarditis, Kaposi sarcoma (HIV), opportunistic infections post-transplant. Consider myocardial biopsy in refractory cases.

Drug interactions

Ticagrelor and clopidogrel have significant CYP3A4 / CYP2C19 interactions with antiretrovirals, antifungals, and immunosuppressants. Consult pharmacy for interaction checks (use AMH Drug Interactions or Micromedex).

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cardiovascular disease is the leading cause of the health gap between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians. The AIHW reports that Indigenous Australians experience acute coronary syndromes at 1.7 times the rate of non-Indigenous Australians and are significantly more likely to die from ischaemic heart disease before the age of 65. Culturally safe, community-centred approaches are essential to improving outcomes.

Burden of disease

Ischaemic heart disease accounts for 12 % of the Indigenous health gap. ACS hospitalisation rates are 1.7× higher; out-of-hospital cardiac arrest mortality is disproportionately high in remote communities.

Earlier age of onset

Indigenous Australians present with ACS approximately 10–15 years younger than non-Indigenous Australians. Ischaemic heart disease should be considered in young adults (30–45 years) with risk factors.

Risk factor prevalence

Higher rates of smoking (40 % vs 12 %), diabetes (type 2, 3–4× higher prevalence), obesity, hypertension, chronic kidney disease, and rheumatic heart disease. These factors drive earlier and more severe atherosclerosis.

Remote and rural access

Access to PCI-capable catheterisation laboratories is limited in remote NT, WA, and QLD communities. Retrieval and transfer times may exceed 2 hours, making pre-hospital fibrinolysis (tenecteplase) the primary reperfusion strategy for STEMI. Royal Flying Doctor Service (RFDS) and CareFlight facilitate transfers.

ECG interpretation via telehealth

Remote health centres can transmit 12-lead ECGs to tertiary hospitals via the Australian Telestroke Network or Cardiobank systems for rapid Code STEMI activation. Ensure all remote clinics have functioning ECG machines and trained operators.

Rheumatic heart disease overlap

RHD remains 6× more common in Indigenous Australians and can mimic or co-exist with ACS (chest pain, ECG changes, elevated troponin in acute rheumatic fever). Consider echocardiography in young Indigenous patients with chest pain and new murmurs.

ACCHS-facilitated follow-up

Aboriginal Community Controlled Health Services (ACCHS) are critical for post-ACS care: cardiac rehabilitation, medication adherence (DAPT, statins), smoking cessation, and chronic disease management. Support wraparound care through Aboriginal Health Workers and Practitioners.

Cultural safety

Use culturally appropriate communication (avoid medical jargon, use visual aids); acknowledge the role of family and community in health decisions; ensure gender-concordant care where requested; recognise that 'sorry business' and social determinants (housing, food security, transport) affect attendance and adherence.

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Key recommendation: All health services managing chest pain in Indigenous communities should have protocols for rapid ECG transmission, pre-hospital fibrinolysis, and retrieval coordination. Engage local ACCHS for post-discharge care planning and ensure medications are available through Remote Area Aboriginal Health Services (RAAHS) supply or Section 100 (S100) PBS provisions.

📚 References

1. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation. 2021;144(22):e368–e454.
2. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289–1367.
3. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895–951.
4. Than M, Herbert M, Flaws D, et al. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the Emergency Department? A clinical survey. Int J Cardiol. 2013;166(3):752–754.
5. Cullen L, Mueller C, Westermann D, et al. An accelerated diagnostic protocol using a single high-sensitivity troponin T measurement at presentation to safely rule-out acute myocardial infarction. Am Heart J. 2013;166(6):1010–1016.
6. Australian Commission on Safety and Quality in Health Care (ACSQHC). Acute Coronary Syndromes Clinical Care Standard. Sydney: ACSQHC; 2019 (updated 2023).
7. Australian Institute of Health and Welfare (AIHW). Heart, stroke and vascular disease — Australian facts. Cat. no. CVD 87. Canberra: AIHW; 2023.
8. SCOT-HEART Investigators. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. 2018;379(10):924–933.
9. National Heart Foundation of Australia. Reducing risk in heart disease: An expert guide to clinical practice for secondary prevention of coronary heart disease. Melbourne: NHFA; 2012 (updated 2020).
10. Brown A, Carrington MJ, McGrady M, et al. Cardiometabolic risk and disease in Indigenous Australians: the Heart of the Heart Study. Int J Cardiol. 2014;171(3):377–383.
11. RHDAustralia (Rheumatic Heart Disease Australia). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition). Darwin: RHDAustralia; 2020.
12. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. J Am Coll Cardiol. 2014;64(24):e139–e228.
13. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231–2264.
14. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book). 9th edn. Melbourne: RACGP; 2018 (updated 2023).

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).