What is the plan of care for a patient presenting with atypical chest pain?

Plan of Care for Atypical Chest Pain

The plan of care for patients with atypical chest pain should follow structured clinical decision pathways that focus on early identification or exclusion of life-threatening causes, with appropriate risk stratification guiding subsequent diagnostic testing. 1

Initial Assessment and Triage

• Obtain a focused history including characteristics and duration of symptoms, associated features, and cardiovascular risk factors 1, 2
• Perform a 12-lead ECG within 10 minutes of arrival to identify ST-segment elevation or other acute coronary syndrome indicators 2
• Measure cardiac troponin levels (preferably high-sensitivity) as soon as possible after presentation 1, 2
• Place patient on cardiac monitor with emergency resuscitation equipment nearby 2
• Consider supplemental ECG leads (V7-V9) if initial ECG is nondiagnostic but clinical suspicion for ACS remains high 2
• Obtain chest radiography to evaluate for cardiac, pulmonary, or thoracic causes of chest pain 2, 3

Risk Stratification

• Use evidence-based diagnostic protocols to estimate risk for coronary artery disease and adverse events 1
• Consider clinical prediction rules such as the Marburg Heart Score or INTERCHEST to estimate ACS risk 4
• Recognize that chest pain is the dominant symptom for both men and women with ACS, though women may present more frequently with accompanying symptoms like nausea and shortness of breath 1
• Note that pain reproducible by palpation is more likely musculoskeletal than ischemic 3
• Remember that relief with nitroglycerin should not be used as a diagnostic criterion for myocardial ischemia 2

Diagnostic Testing Based on Risk Level

High-Risk Features

• Patients with high-risk features (recurrent ischemia, elevated troponin, hemodynamic instability, major arrhythmias) require immediate attention 2
• Follow ACS guidelines with consideration for immediate reperfusion therapy for STEMI or high-risk features 2

Intermediate Risk

• Patients with acute or stable chest pain at intermediate risk will benefit most from cardiac imaging and testing 1
• Consider exercise stress testing, coronary computed tomography angiography (CCTA), or cardiac magnetic resonance imaging (CMR) 5, 4
• CMR is particularly useful to distinguish chest pain due to type 1 AMI versus supply-demand mismatch due to acute cardiac noncoronary artery disease 5

Low Risk

• For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed 1
• Consider alternative diagnoses such as musculoskeletal pain, gastroesophageal reflux disease, or anxiety/panic disorder 3, 4
• Screen for panic disorder using validated questionnaires 3

Shared Decision-Making

• Include clinically stable patients in decision-making 1
• Provide information about risk of adverse events, radiation exposure, costs, and alternative options 1
• Discuss the relatively low mortality rate (2.9% at one year) for patients with atypical chest pain compared to those with confirmed cardiac events (18.3%) 6

Common Pitfalls and Considerations

• Avoid using the term "atypical" as it is misleading; instead use "noncardiac" if heart disease is not suspected 1
• Remember that women, elderly patients, and those with diabetes may present with atypical symptoms such as shortness of breath, nausea, or vague abdominal symptoms 2
• Consider that 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 1
• Be aware that physical examination contributes minimally to diagnosing heart attack unless there is associated shock 2
• Recognize that even after one year of follow-up, a sizeable minority of patients with atypical chest pain remain undiagnosed 6

Follow-up Considerations

• Establish a clear follow-up plan for patients discharged without a definitive diagnosis, as symptoms often persist or recur 6
• Consider that musculoskeletal causes are the most common etiology of atypical chest pain 6
• Be aware that approximately half of patients with atypical chest pain will undergo further investigations within a year, with about 14% requiring readmission 6