What is the best diagnostic approach for intermittent chest pain over 2 years?

Diagnostic Approach for Intermittent Chest Pain Over 2 Years

For a patient with intermittent chest pain lasting 2 years, begin with a focused cardiovascular history assessing specific pain characteristics, cardiovascular risk factors, and an ECG, then stratify risk to determine whether cardiac stress testing or anatomic imaging is needed—low-risk patients require no urgent testing. 1

Initial Clinical Assessment

Essential History Elements

Obtain specific details about the chest pain characteristics 1, 2:

• Exact location and radiation pattern: Substernal discomfort radiating to left arm, neck, or jaw suggests cardiac ischemia 1
• Quality: Pressure, tightness, or squeezing (rather than sharp or stabbing) is more consistent with angina 1
• Temporal pattern: Note onset, duration of each episode, and frequency over the 2-year period 2
• Precipitating factors: Pain provoked by exertion or emotional stress suggests ischemia; positional pain suggests musculoskeletal causes 1
• Relieving factors: Relief with rest is consistent with stable angina, though nitroglycerin response should NOT be used diagnostically as esophageal spasm also responds 1, 2
• Associated symptoms: Dyspnea, diaphoresis, nausea, lightheadedness, or upper abdominal discomfort suggest cardiac origin 1

Cardiovascular Risk Factor Assessment

Document age, sex, diabetes, hypertension, hyperlipidemia, smoking history, and family history of premature coronary artery disease 2, 3. A combination of age, sex, and chest pain characteristics predicts likelihood of coronary artery disease. 4

Physical Examination

Perform focused cardiovascular examination looking for 1, 2:

• Diaphoresis, tachycardia, hypotension (suggests acute process)
• S3 gallop or new murmurs (suggests heart failure or valvular disease)
• Chest wall tenderness (suggests musculoskeletal cause)
• Pulse differentials (suggests aortic dissection, though unlikely with 2-year history)

Mandatory Initial Testing

Electrocardiogram

Obtain a 12-lead ECG in all patients with suspected cardiac chest pain. 2, 3 Look for:

• ST-segment changes, T-wave inversions, or Q waves suggesting ischemia or prior infarction 3, 4
• Left bundle branch block, which may mask ischemic changes 1
• Consider supplemental leads V7-V9 if posterior MI suspected 1, 3

Chest Radiograph

Obtain chest X-ray to evaluate alternative cardiac, pulmonary, and thoracic causes including pneumonia, heart failure, or mediastinal abnormalities 1, 3

Risk Stratification Algorithm

Describe Pain as "Cardiac," "Possible Cardiac," or "Noncardiac"

Avoid the term "atypical chest pain" as it is misleading and often incorrectly implies noncardiac origin. 1 Instead, use specific descriptors based on likelihood of ischemia 1.

Apply Clinical Decision Pathways

Use structured risk assessment tools to categorize patients into low-, intermediate-, or high-risk strata. 1 The Marburg Heart Score and INTERCHEST clinical decision rule can estimate acute coronary syndrome risk 4.

Further Testing Based on Risk Stratification

Low-Risk Patients

For patients determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed. 1 Consider non-cardiac causes such as:

• Musculoskeletal pain (costochondritis)—reproducible by palpation 5, 4
• Gastroesophageal reflux disease—burning retrosternal pain related to meals 6
• Panic disorder—screen with two-item questionnaire 5

Intermediate-Risk Patients

Patients at intermediate risk will benefit most from cardiac imaging and testing. 1 Options include 1, 4:

• Exercise stress testing (if able to achieve ≥5 METs and no baseline ECG abnormalities) 1
• Coronary computed tomography angiography (CCTA) 4
• Stress echocardiography or nuclear perfusion imaging 1
• Cardiac magnetic resonance imaging 4

High-Risk Patients

Patients with recurrent ischemic symptoms, elevated troponin (if measured), hemodynamic instability, or high-risk ECG findings require urgent cardiology consultation and consideration of invasive coronary angiography 3.

Critical Pitfalls to Avoid

• Do not rely on nitroglycerin response as a diagnostic criterion, since esophageal disorders also respond 1, 2
• Do not assume young age excludes coronary disease, as acute coronary syndrome can occur even in adolescents 2, 6
• Do not dismiss sharp or pleuritic pain as automatically noncardiac, since pericarditis presents this way 2, 6
• Remember that women may present with accompanying symptoms like nausea, fatigue, and dyspnea rather than classic chest pressure 1, 2
• In elderly patients (≥75 years), consider ACS even with atypical presentations like isolated dyspnea, syncope, or delirium without chest pain 2

Shared Decision-Making

Include clinically stable patients in decision-making about testing options, discussing risks of adverse events, radiation exposure, costs, and alternatives. 1 This is particularly important for intermediate-risk patients where multiple testing modalities are available 1.