How can a patient determine that chest pain is non-cardiac in nature

How Patients Can Determine Chest Pain is Non-Cardiac

Patients cannot reliably determine on their own that chest pain is non-cardiac—this requires medical evaluation with ECG and troponin testing to exclude life-threatening cardiac causes first. 1

Critical Safety Warning

• Any new chest pain requires immediate medical evaluation by calling 9-1-1, as only 5.1% of ED chest pain patients have acute coronary syndrome, but missing it can be fatal 1
• Patients should never self-diagnose chest pain as non-cardiac without proper cardiac workup including ECG within 10 minutes and troponin measurement 1
• Even pain that seems "obviously" non-cardiac may be ischemic in origin 1

Features Suggesting LOWER Likelihood of Cardiac Origin

While these features suggest lower cardiac probability, they do NOT rule out cardiac disease and medical evaluation is still mandatory 1:

Pain Characteristics That Suggest Non-Cardiac Causes:

• Sharp, stabbing, or fleeting pain (lasting only seconds) 1
• Pleuritic pain (worsens with deep breathing or inspiration) 1, 2
• Positional pain (changes with body position or movement) 1
• Point tenderness (pain reproducible by pressing on a specific spot on the chest wall) 1, 3
• Pain that shifts locations frequently 1
• Right-sided chest pain (though cardiac pain can occasionally present this way) 1

Duration Patterns:

• Pain lasting only a few seconds is unlikely to be cardiac 1
• Cardiac ischemic pain typically builds gradually over several minutes 1

Features Suggesting HIGHER Likelihood of Cardiac Origin

These features require immediate emergency evaluation 1:

High-Risk Pain Characteristics:

• Pressure, squeezing, heaviness, tightness, or gripping sensation in the chest 1
• Central or left-sided substernal discomfort 1
• Exertional or stress-related pain (brought on by physical activity or emotional stress) 1
• Pain radiating to left shoulder, arm, jaw, neck, or upper abdomen 1, 4
• Pain described as "dull" or "aching" 1

Associated Symptoms Requiring Emergency Evaluation:

• Shortness of breath or dyspnea 1, 4
• Nausea (particularly common in women with ACS) 1
• Diaphoresis (sweating) 1
• Syncope or near-syncope 1
• In elderly patients ≥75 years: acute delirium or unexplained falls 1

Common Non-Cardiac Causes (After Cardiac Exclusion)

These diagnoses can only be considered AFTER proper cardiac workup 2, 5:

Musculoskeletal (Most Common):

• Costochondritis: Pain reproducible with palpation of costochondral junctions 2
• Cervical radiculopathy: Pain radiating from cervical spine 2

Gastrointestinal:

• GERD (most common esophageal cause): Can perfectly mimic angina with radiation, described as compression or burning 4, 2, 5
• Peptic ulcer disease: Epigastric pain radiating to chest 2

Pulmonary (Life-Threatening):

• Pulmonary embolism: Chest pain with dyspnea and tachycardia in >90% of cases, particularly in sedentary smokers 4, 2
• Pneumothorax: Pleuritic pain with unilateral decreased breath sounds 2
• Pneumonia: Localized pleuritic pain with friction rub 2

Psychological:

• Panic disorder and anxiety: Often with multiple somatic symptoms 2, 5

The Proper Diagnostic Algorithm

Patients must follow this sequence—self-diagnosis is dangerous 1, 4:

1. Immediate ED evaluation for any new or changing chest pain 1
2. ECG within 10 minutes of arrival 1
3. Troponin measurement (preferably high-sensitivity) as soon as possible 1, 6
4. Chest radiograph to evaluate for pulmonary causes 4, 3
5. If cardiac causes excluded, then consider non-cardiac workup including:
   • Trial of proton pump inhibitors for suspected GERD 4, 2
   • Upper endoscopy if esophageal cause suspected 4, 2
   • Evaluation for psychological factors if all organic causes excluded 4, 2

Critical Pitfalls to Avoid

• Never assume relief with nitroglycerin confirms cardiac origin—this is not a reliable diagnostic criterion 6
• Never assume lack of relief with nitroglycerin excludes cardiac origin 6
• Women may present with more accompanying symptoms (nausea, shortness of breath) rather than classic chest pressure 1, 6
• Elderly patients and diabetics may have atypical presentations including vague symptoms without chest pain 6
• Some life-threatening non-cardiac causes (pulmonary embolism, aortic dissection, esophageal rupture) require immediate identification 2

Bottom Line for Patients

The term "atypical chest pain" should be abandoned—instead, chest pain should be classified as cardiac, possibly cardiac, or noncardiac ONLY after proper medical evaluation. 1 Patients cannot make this determination themselves, as more than half of ED chest pain is ultimately non-cardiac, but distinguishing this requires objective testing that only healthcare providers can perform 1.