Chest Pain and Jaw Pain During Dipyridamole Stress Testing
Chest pain and jaw pain during a dipyridamole stress test are common side effects that do NOT indicate a positive test for ischemia—only new wall motion abnormalities on imaging or reversible perfusion defects constitute a positive result. 1, 2
Understanding Symptoms vs. Positive Test Results
The critical distinction is that symptoms alone (chest pain, jaw pain) are not diagnostic findings during dipyridamole stress testing. The test is positive only when:
- Reversible perfusion defects appear on nuclear imaging (present during stress but not at rest) 1, 3
- New or worsening wall motion abnormalities develop on echocardiography 4, 5, 6
Chest pain occurs in approximately 20-57% of patients during dipyridamole infusion and represents a known side effect rather than a diagnostic criterion 7, 8. Similarly, jaw pain is a recognized adverse effect of vasodilator stress agents 2.
Why Symptoms Occur Without Ischemia
Dipyridamole causes maximal coronary vasodilation through adenosine receptor stimulation, which can produce chest discomfort through several non-ischemic mechanisms 4, 3:
- Direct adenosine receptor stimulation in chest wall tissues
- Bronchial smooth muscle effects
- Systemic vasodilation causing reflex tachycardia
- Headache, flushing, and nausea through similar mechanisms 4, 2
Importantly, studies demonstrate that patients with angiographically normal coronary arteries frequently experience chest pain during dipyridamole testing without any wall motion abnormalities or perfusion defects 7, 8. This confirms that symptoms are unreliable indicators of true myocardial ischemia.
When Symptoms Require Intervention
While symptoms don't indicate test positivity, severe chest pain or bronchospasm requires immediate treatment with intravenous aminophylline (50-250 mg over 30-60 seconds) 2. The FDA drug label specifies that vital signs must be monitored during and for 10-15 minutes following dipyridamole infusion 2.
Critical warning signs that distinguish dangerous complications from benign side effects include 2:
- Severe, persistent chest pain unrelieved by aminophylline (consider myocardial infarction)
- Severe bronchospasm (occurs in 0.2% of patients)
- Significant hypotension requiring supine positioning
- Ventricular arrhythmias or conduction abnormalities
The Diagnostic Standard
Only imaging findings determine test results 1, 9:
- Normal scan = excellent prognosis with annual cardiac death rate of approximately 2% 1
- Reversible defects = hemodynamically significant CAD requiring further evaluation 1
- More than 3 reversible defects or >20% of myocardial segments involved = highest risk requiring aggressive management 1
Common Pitfall to Avoid
Do not interpret the presence of chest pain or jaw pain during dipyridamole stress as indicating a positive test or requiring coronary angiography. This leads to unnecessary invasive procedures in patients with normal perfusion imaging 1, 7, 8. The imaging findings—not the symptoms—drive clinical decision-making and risk stratification 1, 9.