From the Guidelines
Atypical chest pain is a problematic term and its use is discouraged, instead, emphasis should be placed on specific aspects of symptoms that suggest their origin in terms of probable ischemia. The criteria for what was previously referred to as atypical chest pain include pain that is sharp or stabbing rather than pressure-like, pain localized to a small area that can be pointed to with one finger, pain that changes with position or breathing, pain lasting very briefly (seconds) or for prolonged periods (days), pain that can be reproduced by pressing on the chest wall, and pain unrelated to physical exertion 1. Some key characteristics of chest pain that may indicate a lower probability of ischemia include:
- Point tenderness, which renders ischemia less likely
- Pain that is sharp or stabbing rather than pressure-like
- Pain localized to a small area that can be pointed to with one finger
- Pain that changes with position or breathing
- Pain lasting very briefly (seconds) or for prolonged periods (days)
- Pain that can be reproduced by pressing on the chest wall
- Pain unrelated to physical exertion It's essential to note that atypical presentations of cardiac pain are common, especially in women, elderly patients, and those with diabetes, so cardiac causes should still be considered even when pain presents atypically 1. A thorough evaluation including medical history, physical examination, and appropriate diagnostic tests is essential to determine the underlying cause of chest pain, and to diminish ambiguity, use “cardiac,” “possible cardiac,” and “noncardiac” to describe the suspected cause of chest pain is encouraged 1.
From the Research
Definition of Atypical Chest Pain
- Atypical chest pain refers to chest pain that does not exhibit the typical characteristics of cardiac-related chest pain, such as pain radiating to the arm, jaw, or neck, or pain triggered by exertion or relieved by rest 2, 3.
- The distinction between "atypical" and "typical" chest pain may not be sufficient to address nonischemic clinical pictures, and a more interdisciplinary approach to diagnosis is recommended 4.
Diagnostic Approach
- The initial approach to patients with atypical chest pain is to rule out myocardial ischemia and other life-threatening causes, such as pulmonary embolism and aortic dissection 5.
- A normal electrocardiogram and serum levels of myocardial necrosis markers within reference ranges may indicate non-cardiac causes of chest pain, such as osteoporotic vertebral fractures of the thoracic spine 2.
- A multi-causal model that considers both psychological and physical factors may be helpful in managing atypical non-cardiac chest pain 3.
Characteristics of Atypical Chest Pain
- Atypical chest pain can be caused by a variety of non-cardiac conditions, including musculoskeletal, gastrointestinal, and pulmonary disorders 2, 5.
- The pain may be recurrent and persistent, and may not respond to traditional cardiac treatments 3.
- Psychological factors, such as anxiety and depression, may play a role in the development and maintenance of atypical chest pain 3.