We don't use the term 'Atypical Chest Pain" anymore. Find out why.

 

We don't use the term 'Atypical Chest Pain" anymore. Find out why.

Chest pain has traditionally been categorized into "typical" and "atypical." 

Typical chest pain, more likely related to ischemia, includes substernal discomfort triggered by physical exertion or emotional stress and alleviated by rest or nitroglycerin.

The more classic the symptoms in terms of quality, location, radiation, and triggers, the higher the likelihood of a cardiac ischemic origin. 

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The term "atypical chest pain" is problematic as it was originally meant to describe angina without typical symptoms, but it often implies a non-cardiac cause. Therefore, the use of "atypical chest pain" is discouraged. Instead, focus on specific symptom characteristics to determine the likelihood of ischemia.

 Chest pain broadly includes referred pain in the shoulders, arms, jaw, neck, and upper abdomen. To reduce ambiguity, it is recommended to describe chest pain as "cardiac," "possible cardiac," or "noncardiac" based on the suspected cause.

So how do we describe "chest pain?"

A thorough history should be obtained from all patients to capture all characteristics of chest pain, including: 1) its nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms. This detailed information can help more accurately identify potential cardiac causes. See Table below: 

Table 1. Chest Pain Characteristics and Corresponding Causes

Nature

Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing)

Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (eg, these symptoms usually occur with acute pericarditis).

Onset and duration

Anginal symptoms gradually build in intensity over a few minutes.

Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome.

Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease.

Location and radiation

Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.

Severity

Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg, aortic dissection).

Precipitating factors

Physical exercise or emotional stress are common triggers of anginal symptoms.

Occurrence at rest or with minimal exertion associated with anginal symptoms usually indicates ACS.

Positional chest pain is usually nonischemic (eg, musculoskeletal).

Relieving factors

Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.

Associated symptoms

Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting.

Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or abdomen may occur in patients with diabetes, women, and elderly patients.

ACS indicates acute coronary syndrome.

While chest pain can stem from various sources, it's essential to prioritize the assessment of potentially life-threatening conditions like ACS, PE, aortic dissection, and esophageal rupture to swiftly administer the right treatment (See Table 2 below). Certain indicators, such as chest tenderness upon palpation or pain worsened by breathing in, significantly lower the likelihood of ACS. It's vital to integrate these findings with other aspects of the evaluation process to accurately diagnose the condition.

Table 2. Physical Examination in Patients With Chest Pain
Clinical Syndrome	Findings
Emergency
ACS	Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR murmur.2; examination may be normal in uncomplicated cases
PE	Tachycardia + dyspnea—>90% of patients; pain with inspiration
Aortic dissection	Connective tissue disorders (eg, Marfan syndrome), extremity pulse differential (30% of patients, type A>B) Severe pain, abrupt onset + pulse differential + widened mediastinum on CXR >80% probability of dissection Frequency of syncope >10%, AR 40%–75% (type A)
Esophageal rupture	Emesis, subcutaneous emphysema, pneumothorax (20% patients), unilateral decreased or absent breath sounds
Other
Noncoronary cardiac: AS, AR, HCM	AS: Characteristic systolic murmur, tardus or parvus carotid pulse AR: Diastolic murmur at right of sternum, rapid carotid upstroke HCM: Increased or displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur
Pericarditis	Fever, pleuritic chest pain, increased in supine position, friction rub
Myocarditis	Fever, chest pain, heart failure, S3
Esophagitis, peptic ulcer disease, gall bladder disease	Epigastric tenderness Right upper quadrant tenderness, Murphy sign
Pneumonia	Fever, localized chest pain, may be pleuritic, friction rub may be present, regional dullness to percussion, egophony
Pneumothorax	Dyspnea and pain on inspiration, unilateral absence of breath sounds
Costochondritis, Tietze syndrome	Tenderness of costochondral joints
Herpes zoster	Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and dermatomal distribution)
ACS indicates acute coronary syndrome; AR, aortic regurgitation; AS, aortic stenosis; CXR, chest x-ray; LR, likelihood ratio; HCM, hypertrophic cardiomyopathy; MR, mitral regurgitation; PE, pulmonary embolism; and PUD, peptic ulcer disease.

 

Top 10 Take-Home Messages for the Evaluation and Diagnosis of Chest Pain

1. Chest Pain Means More Than Pain in the Chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.

2. High-Sensitivity Troponins Preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.

3. Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.

4. Share the Decision-Making. Clinically stable patients presenting with chest pain should be included in decision-making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.

5. Testing Not Needed Routinely for Low-Risk Patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.

6. Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.

7. Accompanying Symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.

8. Identify Patients Most Likely to Benefit From Further Testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.

9. Noncardiac Is In. Atypical Is Out. “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged.

10. Structured Risk Assessment Should Be Used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.

Reference:  https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029