What is the appropriate workup and management for a patient with exertional chest pain, particularly those with a history of cardiovascular disease or risk factors such as hypertension, hyperlipidemia, or diabetes mellitus?

Exertional Chest Pain: Causes and Workup

In patients presenting with exertional chest pain, particularly those with cardiovascular risk factors (hypertension, hyperlipidemia, diabetes), coronary artery disease must be assumed until proven otherwise, requiring immediate ECG within 10 minutes, cardiac troponin measurement, and risk stratification to determine the need for urgent invasive versus noninvasive testing. 1, 2

Primary Causes to Consider

Cardiac Ischemic Causes

• Stable angina from obstructive coronary artery disease is the most common cause of exertional chest pain, characterized by substernal discomfort with pressure/heaviness quality, lasting minutes, provoked by exertion, and relieved by rest or nitroglycerin within 30 seconds to several minutes 1
• Unstable angina or NSTEMI presents as new-onset exertional pain, increasing frequency/intensity of prior stable angina, or pain occurring with minimal exertion—these patients require immediate emergency department evaluation 1
• Conditions increasing myocardial oxygen demand include severe uncontrolled hypertension, aortic stenosis, hyperthyroidism, and cocaine use 1
• Conditions decreasing myocardial oxygen supply include anemia, hypoxemia from pulmonary disease, and increased blood viscosity 1

Non-Ischemic Cardiac Causes

• Pericarditis typically presents with sharp pain worsened by inspiration and relieved by sitting forward, with an audible friction rub on examination 1
• Hypertrophic cardiomyopathy may cause exertional chest pain with physical examination revealing a systolic murmur that increases with Valsalva 1

Life-Threatening Non-Cardiac Causes

• Aortic dissection in hypertensive patients presents with sudden-onset severe, ripping chest pain radiating to the back, with pulse differentials between extremities 2, 3
• Pulmonary embolism should be considered in patients with chest pain, dyspnea, and risk factors for venous thromboembolism 3

Initial Workup Algorithm

Immediate Assessment (Within 10 Minutes)

• Obtain 12-lead ECG immediately regardless of whether symptoms appear typical—this is a Class I recommendation 1, 2
• Measure cardiac troponin as soon as possible after presentation, with high-sensitivity troponin preferred 1, 2, 4
• Administer aspirin 250-500 mg (chewable) if no contraindications exist 2

Clinical Characterization

Classify chest pain using these three criteria:

1. Substernal chest discomfort with characteristic quality (pressure, heaviness, tightness, squeezing) and duration (minutes)
2. Provoked by exertion or emotional stress
3. Relieved by rest or nitroglycerin 1

• Typical angina meets all three criteria 1
• Atypical angina meets two of three criteria 1
• Noncardiac chest pain meets one or none of the criteria 1

Critical caveat: Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely angina 1

Risk Factor Assessment

Document the following cardiovascular risk factors, as their presence significantly increases pretest probability of coronary artery disease:

• Smoking (increases ACS risk) 1, 5
• Hyperlipidemia 1
• Diabetes mellitus—particularly important as these patients are at high risk for macrovascular disease and concurrent hypertension/hyperlipidemia 1
• Hypertension 1
• Family history of premature CAD (onset in male first-degree relative <55 years or female <65 years) 1
• History of cerebrovascular or peripheral artery disease 1
• Known coronary artery disease or prior MI 1, 6

Physical Examination Findings

• Examination is often normal in stable angina but may reveal conditions that precipitate or mimic ischemia 1
• Elevated blood pressure suggests uncontrolled hypertension as a precipitant 1
• Systolic murmur may indicate aortic stenosis or ischemic mitral regurgitation (the latter associated with poor prognosis) 1
• Pulse differentials or diminished pedal pulses suggest vascular disease 1
• Pain reproducible by chest wall palpation suggests musculoskeletal etiology but does not eliminate possibility of angina 1

Risk Stratification and Disposition

High-Risk Features (Immediate Invasive Strategy)

Patients with the following require immediate cardiac catheterization:

• Ongoing chest pain with ischemic ECG changes (ST-segment elevation or depression) 2, 4
• Elevated troponin with recurrent ischemia 2, 4
• Hemodynamic instability 2, 4
• Major arrhythmias 2, 4
• Diabetes with positive troponin 2

Intermediate-Risk (Hospital Admission for Invasive Strategy Within 24-48 Hours)

• Positive troponin without high-risk features 2, 4
• New or worsening angina with cardiovascular risk factors 1

Low-Risk (Outpatient Stress Testing)

Patients with all of the following can proceed with outpatient evaluation:

• Normal troponin at presentation and 6-12 hours later 2, 4
• No recurrent chest pain 2
• No ECG changes 2
• Hemodynamic stability 2

Important caveat: More than 50% of patients with chronic stable angina have normal resting ECG, so normal ECG does not exclude coronary artery disease 1

Noninvasive Testing Selection

When Resting ECG Shows Abnormalities

• Evidence of prior MI (Q waves, especially in multiple leads) indicates worse prognosis and higher likelihood of CAD 1
• ST-T wave changes consistent with ischemia favor CAD diagnosis 1
• Left ventricular hypertrophy suggests increased risk 1
• Left bundle-branch block, bifascicular block, or AV block are suggestive but nonspecific indicators of CAD 1

Stress Testing Approach

• Exercise stress testing is appropriate for patients who can exercise and have interpretable baseline ECG 1
• Stress imaging (nuclear or echocardiography) is preferred for patients with baseline ECG abnormalities that preclude interpretation 1
• Coronary CT angiography may be considered in intermediate-risk patients 1

Critical pitfall: Electron-beam computed tomography is NOT recommended as a screening test for CAD due to poor specificity (39.9%-49.2%) despite reasonable sensitivity 1

Direct Angiography Indications

In unusual circumstances, direct referral for cardiac angiography may be appropriate for:

• Survivors of sudden cardiac death 1
• Congestive heart failure 1
• Stable but severe symptoms with multiple cardiac risk factors 1

Special Considerations

Patients with Diabetes

• Diabetes is a particularly important risk factor requiring heightened suspicion 1
• These patients may present with atypical symptoms including isolated dyspnea 1
• Lower threshold for advanced testing is warranted 4

Women and Elderly Patients

• Chest pain in women is less often due to ischemic heart disease than in men, even when pain appears typical 1
• Elderly patients (>75 years) may present with atypical symptoms including confusion, presyncope, syncope, or vague abdominal symptoms 4

Conditions That May Elevate Troponin Without ACS

• Severe hypothyroidism can cause troponin elevation and chest pain without coronary artery disease 7
• Renal insufficiency, myocarditis, and pulmonary embolism may also elevate troponin 1