Chest pain triage in primary care — KFP-style written assessment

KFP 1 (10 marks)

A 48-year-old smoker presents with a first episode of central chest tightness while walking uphill, resolving after two minutes of rest. ECG is normal. He has no nausea or sweating, and the pain was retrosternal. He is 48. ^{[4] [8]}

1. Calculate his Marburg Heart Score and interpret it. (4) ^[4]
2. What does a normal ECG contribute — and what does it not exclude? (3) ^[4]
3. Given his smoking and exertional pattern, what is the appropriate disposition? (3) ^[6]

Model answers

1. MHS = 2: normal ECG (0), age below 65 (1), pain retrosternal (0), no nausea/vomiting (1), no diaphoresis (1). A score of 2 or less carries high negative predictive value (95.6% for suspected ACS in ED validation) — but this was his first exertional episode, and the score assists rather than replaces judgement. ^{[4] [13]}
2. The normal ECG is one reassuring MHS element and never excludes coronary artery disease — stable CAD produces normal resting ECGs routinely. It also cannot exclude an evolving ACS; if any doubt persists, hs-troponin pathways (troponin I under 6 ng/L with under 4 ng/L delta at 45-120 minutes: NPV 99.5%, 30-day risk 0.2%) resolve the MI question quickly. ^[8]
3. His exertional retrosternal pattern is at least atypical angina: per NICE CG95, no formal pre-test probability calculation is needed — proceed to CTCA first-line for typical or atypical angina without known CAD, with aggressive smoking cessation in parallel. ^{[6] [7]}