What is the approach to taking a history in a patient presenting with chest pain?

Approach to History Taking in Chest Pain

In patients presenting with chest pain, obtain a focused history that systematically captures six key characteristics: nature, onset/duration, location/radiation, severity, precipitating factors, and relieving factors, along with associated symptoms and cardiovascular risk factor assessment. 1

Systematic Approach to Chest Pain Characteristics

Nature of Pain

• Cardiac/anginal pain is described as retrosternal discomfort using terms like pressure, squeezing, gripping, heaviness, tightness, or constriction—rarely as "pain" itself 1
• Sharp chest pain that worsens with inspiration and lying supine suggests pericarditis, not ischemic heart disease 1
• Stabbing pain has a low likelihood ratio (0.2-0.3) for acute coronary syndrome 2
• Pain reproducible by palpation is more likely musculoskeletal than ischemic (LR 0.2-0.3) 3, 2

Onset and Duration

• Anginal symptoms build gradually over several minutes, not instantaneously 1
• Sudden-onset "ripping" or "tearing" pain radiating to the back suggests acute aortic dissection, not angina 1
• Fleeting pain lasting only seconds is unlikely ischemic heart disease 1
• Pain persisting >20 minutes is highly suggestive of acute myocardial infarction 4

Location and Radiation

• Substernal or precordial location is most common for cardiac ischemia 1, 4
• Pain radiating to one or both shoulders/arms increases likelihood of ACS (LR 2.3-4.7) 2
• Radiation to neck, jaw, or left arm is characteristic of angina 1
• Pain localized to a very small area or radiating below the umbilicus/hip is unlikely myocardial ischemia 1

Severity Assessment

• "Worst chest pain of my life" with sudden onset in a hypertensive patient or someone with known bicuspid aortic valve/aortic dilation suggests acute aortic syndrome 1
• Severe pain is reported in 84.9% of AMI patients 4

Precipitating Factors

• Physical exertion or emotional stress are classic triggers for anginal symptoms 1
• Occurrence at rest or with minimal exertion indicates acute coronary syndrome 1
• Positional chest pain suggests musculoskeletal or other nonischemic causes 1

Relieving Factors

• Relief with nitroglycerin is NOT diagnostic of myocardial ischemia and should not be used as a diagnostic criterion—esophageal spasm and other conditions may also respond 1, 5, 6

Associated Symptoms to Elicit

Cardiac-Specific Symptoms

• Dyspnea, diaphoresis, nausea/vomiting, lightheadedness, presyncope, syncope, or palpitations commonly accompany myocardial ischemia 1
• Upper abdominal pain or heartburn unrelated to meals may represent anginal equivalents 1

Special Population Considerations

• Women, elderly patients, and diabetics may present with atypical symptoms including sharp pain, throat/abdominal discomfort, nausea, fatigue, or isolated dyspnea rather than classic chest pain 1, 5, 6
• These populations face systematic underdiagnosis because risk assessment tools underestimate their cardiac risk 5

Cardiovascular Risk Factor Assessment

Systematically assess:

• Age and sex 1, 6
• Smoking history 1
• Diabetes mellitus 1
• Hypertension 1
• Hyperlipidemia 1
• Family history of premature coronary artery disease 1, 6
• History of cerebrovascular or peripheral vascular disease 1

Critical Terminology Guidance

Avoid the term "atypical chest pain"—it is not helpful in determining cause and can be misinterpreted as benign. Instead, describe chest pain as cardiac, possibly cardiac, or noncardiac because these terms are more specific to the underlying diagnosis 1

Immediate Triage Decision

After obtaining this focused history, categorize patients as:

• Stable angina (chronic symptoms with consistent precipitants like exertion) 1
• Unstable angina/ACS (new onset, rest pain, or crescendo pattern requiring immediate ED evaluation) 1

Patients with high or moderate risk features for short-term death should be promptly transferred to an emergency department or coronary care unit 1

Common Pitfalls to Avoid

• The chest pain history alone, even when comprehensive, has not proven powerful enough to obviate the need for diagnostic testing (ECG, troponin) 2
• There is frequently lack of correlation between symptom intensity and disease seriousness 1
• General similarity of symptoms exists among different causes of chest pain, requiring integration with physical examination, ECG, and biomarkers 1, 3
• Young age does not exclude ACS 6