What history should be taken in a patient presenting with chest pain to identify potential causes and risk factors?

History to Elicit in Chest Pain

In patients presenting with chest pain, obtain a focused history that systematically captures six key pain characteristics (nature, onset/duration, location/radiation, precipitating factors, relieving factors, and associated symptoms) along with cardiovascular risk factor assessment to identify life-threatening conditions and guide appropriate triage. 1

Essential Pain Characteristics to Document

Nature and Quality of Pain

• High probability of ischemia: Pressure, squeezing, gripping, heaviness, tightness, or constriction—patients rarely use the word "pain" itself 1, 2, 3
• Low probability of ischemia: Sharp, stabbing, fleeting (lasting only seconds), pleuritic, or localized to a very small area 1, 2, 3
• Sharp pain that worsens with inspiration and lying supine suggests pericarditis rather than ischemic disease 1, 4
• Sudden-onset "ripping" or "tearing" quality indicates possible aortic dissection 2, 3, 4

Temporal Features

• Onset pattern: Anginal pain builds gradually over several minutes, not instantaneously 1, 2
• Duration: Document exact timing relative to presentation 1
• Fleeting pain lasting only seconds is unlikely to represent myocardial ischemia 2, 3

Location and Radiation Pattern

• Typical cardiac location: Retrosternal, substernal, or precordial 1, 2, 3
• Characteristic radiation: Left arm, neck, jaw, or shoulders 1, 2, 3
• Pain localized to a very limited area or radiating below the umbilicus/hip is unlikely ischemic 2, 3
• Remember that chest pain encompasses discomfort in shoulders, arms, neck, back, upper abdomen, or jaw—not just the chest itself 4

Precipitating and Relieving Factors

• Ischemic triggers: Physical exertion, emotional stress, or occurring at rest (suggesting ACS) 1, 2
• Positional factors: Pain worse when lying supine and improved when leaning forward suggests pericarditis 1, 4
• Mechanical factors: Pain affected by palpation, breathing, turning, twisting, or bending suggests musculoskeletal etiology 2, 4
• Critical pitfall: Do NOT use nitroglycerin response as a diagnostic criterion—esophageal spasm and other noncardiac conditions also respond to nitroglycerin 1, 2, 4

Associated Symptoms That Increase ACS Likelihood

Classic Accompanying Features

• Dyspnea or shortness of breath 1
• Diaphoresis (sweating) 1, 2, 3
• Nausea or vomiting 1, 2, 3
• Lightheadedness, presyncope, or syncope 1, 2, 3
• Palpitations 2, 3
• Upper abdominal pain or "heartburn" unrelated to meals may represent anginal equivalents 3

Cardiovascular Risk Factor Assessment

Essential Risk Factors to Document

• Age and sex 1
• Diabetes mellitus 1, 2, 3
• Hypertension 1, 2, 3
• Hyperlipidemia 1, 2, 3
• Current smoking status 2, 3
• Family history of premature coronary artery disease 1, 2, 3
• Prior history of myocardial infarction or known coronary artery disease 2

Medication History

• Current anticoagulants and antiplatelet agents 4
• Erectile dysfunction medications (contraindication to nitrates) 4

Special Population Considerations

Women-Specific History

Women are at high risk for underdiagnosis and potential cardiac causes must always be considered. 1, 3

• Emphasize accompanying symptoms more common in women: Nausea, fatigue, shortness of breath, jaw pain, neck pain, and back pain alongside or instead of classic chest pain 1, 2, 3
• Women may present with prodromal symptoms when seeking care 1
• Chest pain remains the predominant symptom in women with ACS, occurring with equal frequency to men 1

Older Adults (≥75 Years)

Consider ACS when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained falls—even without classic chest pain. 1, 3

• Elderly patients frequently present with atypical symptoms 2, 3
• May have isolated dyspnea without chest discomfort 2

Patients with Diabetes

• More likely to present with atypical symptoms including vague abdominal symptoms, confusion, or isolated dyspnea 1, 2
• Higher risk for silent ischemia 1

Critical Terminology to Use

Avoid the term "atypical chest pain"—instead describe chest pain as cardiac, possibly cardiac, or noncardiac, as these terms are more specific to the potential underlying diagnosis. 1, 3

This terminology prevents misinterpretation of symptoms as benign and ensures appropriate risk stratification 1

Red Flags Requiring Immediate Action

High-Risk Historical Features

• Prolonged ongoing rest pain 2
• Hemodynamic instability 2, 4
• Age >75 years with accompanying symptoms 1, 3
• Multiple cardiovascular risk factors 2
• Prior history of ACS or coronary artery disease 2

Life-Threatening Presentations

• Sudden-onset tearing/ripping pain radiating to back (aortic dissection) 2, 3, 4
• Acute dyspnea with pleuritic pain (pulmonary embolism) 2, 3, 4
• Severe pain with subcutaneous emphysema (esophageal rupture) 3

Common Pitfalls to Avoid

• Never dismiss chest pain in women or elderly patients who frequently present with atypical symptoms 2, 4
• Do not assume young age excludes ACS—it can occur even in adolescents without traditional risk factors 2
• Sharp, pleuritic pain does not exclude ACS—pericarditis and atypical presentations can occur 2
• Relief with antacids does not exclude cardiac etiology—overlap exists between cardiac and gastrointestinal symptoms 4
• Do not delay transfer to ED for additional history-taking if clinical evidence of ACS or life-threatening causes is present 1, 3