From the Guidelines
Chest pain should no longer be classified as "atypical" or "typical", but rather as "cardiac", "possible cardiac", or "noncardiac" to describe the suspected cause of chest pain, as the term "atypical" is misleading and discouraged by the American College of Cardiology and American Heart Association 1.
Classification of Chest Pain
The traditional classification of chest pain into "typical" and "atypical" types is no longer recommended. Instead, clinicians should focus on specific aspects of symptoms that suggest their origin in terms of probable ischemia.
- Chest pain that is more likely associated with ischemia consists of substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin.
- The more classic the chest discomfort is based on quality, location, radiation, and provoking and relieving factors, the more likely it is to be of cardiac ischemic origin.
- Clinicians should assess these features along with risk factors like age, sex, diabetes, hypertension, smoking, and family history to estimate pre-test probability of coronary disease.
Diagnostic Approach
When evaluating chest pain, clinicians should use a structured risk assessment to estimate the risk of coronary artery disease and adverse events.
- The Diamond-Forrester criteria can be used to estimate pre-test probability of coronary disease.
- Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.
- High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury 1.
Patient Evaluation
Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1.
- Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.
- Clinically stable patients presenting with chest pain should be included in decision-making, and information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion 1.
From the Research
Definition of Chest Pain
Chest pain can be defined as typical, atypical, or nonanginal, with each category having distinct characteristics.
- Typical chest pain is often associated with myocardial ischemia, while atypical chest pain may have other life-threatening causes, such as pulmonary embolism or aortic dissection 2.
- A study published in 2019 compared the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score and clinical coronary artery disease (CAD) consortium (CADC) model for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) in patients with acute chest pain, which was classified as typical, atypical, or nonanginal 3.
Atypical vs Typical Chest Pain
The distinction between atypical and typical chest pain may not be sufficient to address nonischemic clinical pictures, and a new categorization of chest pain into cardiac, possibly cardiac, and (probably) noncardiac causes has been proposed 4.
- This new approach may provide a more interdisciplinary approach to a symptom-oriented diagnostic algorithm.
- However, the diagnostic structures of chest pain units may not currently reflect this new categorization, and an adaptation may be necessary 4.
Predictors of Chest Pain
Several factors can predict the severity and complexity of coronary artery disease, including prior aspirin use and the SYNTAX score 5.
- A study published in 2016 found that prior aspirin use was associated with lower peak troponin levels, while increasing SYNTAX score was associated with higher peak troponin levels 5.
- These findings may help predict patient populations with acute coronary syndrome who would be at a greater risk for short- and long-term cardiovascular morbidity and mortality due to elevated peak troponin 5.