From the Guidelines
Typical cardiac chest pain should be distinguished from non-cardiac chest pain, as the term "atypical" is discouraged due to its potential to mislead diagnosis. The most recent guidelines from the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines 1 emphasize the importance of characterizing chest pain based on its quality, location, radiation pattern, duration, provoking factors, and associated symptoms to determine its likelihood of being cardiac in origin.
Key Characteristics of Chest Pain
- Typical cardiac chest pain is characterized by substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.
- Non-cardiac chest pain, on the other hand, originates from structures outside the heart and can be caused by musculoskeletal, gastrointestinal, pulmonary, or anxiety-related issues.
Diagnostic Approach
- The diagnosis of chest pain should focus on the early identification or exclusion of life-threatening causes, with high-sensitivity troponins being the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction 1.
- Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely to guide diagnosis and treatment.
- Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease will benefit the most from cardiac imaging and testing 1.
Importance of Accurate Diagnosis
- Accurate diagnosis of chest pain is crucial for prompt treatment and to reduce morbidity and mortality associated with cardiac and non-cardiac causes.
- The use of structured risk assessment and evidence-based diagnostic protocols can help identify patients who are most likely to benefit from further testing and treatment 1.
From the Research
Typical Cardiac Chest Pain
- Typical cardiac chest pain is often described as a feeling of pressure, tightness, or heaviness in the chest that may radiate to the arms, back, neck, or jaw 2.
- The diagnosis of acute myocardial infarction based on chest pain typicality has an area under the curve (AUC) of 0.54, indicating limited discriminatory value 2.
Atypical Chest Pain
- Atypical chest pain refers to chest pain that does not fit the typical description of cardiac chest pain 2.
- The traditional 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 noncardiac causes may be more effective 3.
Non-Cardiac Chest Pain
- Non-cardiac chest pain refers to chest pain that is not caused by a cardiac condition 3.
- The evaluation of chest pain should include a thorough clinical assessment, including history, physical examination, and diagnostic testing such as electrocardiogram and cardiac troponin assays 4, 5.
- A new subdivision into cardiac, possibly cardiac, and noncardiac causes of chest pain may help to address the diagnostic challenge of chest pain in the emergency department 3.
Diagnosis and Evaluation
- The diagnosis and evaluation of chest pain should be based on contemporary evidence and guidelines, such as the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain 5.
- The use of clinical decision algorithms, stress testing, and coronary computed tomography angiography can help to rapidly exclude acute myocardial infarction and further risk stratify patients 4, 5.
- Cost-value considerations in diagnostic testing and shared decision-making with patients are important aspects of the evaluation and diagnosis of chest pain 5.