What is atypical chest pain?

Understanding Atypical Chest Pain

The term "atypical chest pain" is misleading and should not be used, as it can be misinterpreted as benign in nature. Instead, chest pain should be described as cardiac, possibly cardiac, or noncardiac because these terms are more specific to the potential underlying diagnosis. 1

Definition and Classification

The 2021 AHA/ACC guidelines specifically discourage the use of the term "atypical chest pain" as it creates confusion and can lead to underdiagnosis of serious conditions. Instead, chest pain should be classified based on its likely origin:

• Cardiac chest pain: Typically presents as substernal chest discomfort that is:

  • Provoked by exertion or emotional stress
  • Relieved by rest or nitroglycerin
  • Often described as pressure, heaviness, tightness, squeezing, or burning
  • May radiate to shoulders, arms, neck, jaw, or upper abdomen

• Noncardiac chest pain: Pain that originates from non-cardiac sources such as:

  • Musculoskeletal (most common non-cardiac cause)
  • Gastrointestinal
  • Pulmonary
  • Psychogenic

Clinical Assessment

When evaluating chest pain that doesn't fit the typical pattern of cardiac ischemia, clinicians should:

1. Obtain a focused history that includes:

   • Precise characteristics of the pain
   • Duration of symptoms
   • Precipitating and relieving factors
   • Associated symptoms
   • Cardiovascular risk factors 1

2. Consider sex differences:

   • Women with cardiac chest pain may present with more accompanying symptoms like nausea and shortness of breath
   • Women are at higher risk for underdiagnosis when presenting with chest pain 1

3. Use structured risk assessment tools rather than relying on subjective impressions of "typicality" 1

Diagnostic Approach

The diagnostic approach should be guided by the probability of cardiac disease:

• Low-risk patients: Urgent diagnostic testing for suspected CAD is not needed 1

• Intermediate-risk or intermediate-to-high pre-test risk patients: These individuals benefit most from cardiac imaging and testing 1

• Clinical decision pathways: Should be used routinely in both emergency department and outpatient settings 1

Common Pitfalls to Avoid

1. Using the term "atypical": This can lead to dismissal of potentially serious causes of chest pain 1

2. Underdiagnosing women: Always consider cardiac causes in women presenting with chest pain, even if symptoms don't fit the "classic" pattern 1

3. Overinvestigation: Patients with non-cardiac chest pain tend to be overinvestigated despite having low mortality rates 2

4. Missing non-cardiac but serious causes: Conditions like pulmonary embolism and aortic dissection can present with chest pain that doesn't fit the typical cardiac pattern 3

5. Neglecting follow-up: Many patients without a clear diagnosis continue to experience symptoms and may require further evaluation 2

Management Considerations

For patients with chest pain that has been determined to be noncardiac:

• Consider referral to appropriate specialists based on suspected etiology (gastroenterologist, psychiatrist, clinical psychologist) 4

• Recognize that conditions like fibromyalgia can present with chest pain initially thought to be cardiac 5

• Implement targeted treatment based on the identified cause rather than continued cardiac testing 4, 5

By following a structured approach to chest pain evaluation and avoiding the misleading term "atypical," clinicians can more effectively diagnose and manage patients, reducing unnecessary testing while ensuring appropriate care for those with cardiac and serious non-cardiac conditions.