What are the recommendations for defining and managing chest pain in adults?

Recommendations for Defining Chest Pain

Chest pain should be categorized as "cardiac," "possibly cardiac," or "noncardiac"—never use the term "atypical" as it is misleading and can result in dangerous misinterpretation of potentially serious conditions. 1

Terminology Framework

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guidelines explicitly recommend abandoning the term "atypical chest pain" because it:

• Fails to help determine the underlying cause 1
• Can be misinterpreted as benign in nature, leading to underdiagnosis 1
• Is not specific to the potential underlying diagnosis 1

Instead, use this three-tier classification system:

• Cardiac: High probability of ischemic origin 1
• Possibly cardiac: Intermediate probability requiring further evaluation 1
• Noncardiac: Low probability when heart disease is not suspected 1

Initial Assessment Requirements

An initial assessment must triage patients based on the likelihood that symptoms are attributable to myocardial ischemia. 1

Essential History Components

Obtain a focused history that includes: 1

• Characteristics of pain: Quality, location, radiation pattern
• Duration of symptoms relative to presentation
• Associated features: Diaphoresis, nausea, dyspnea, palpitations
• Cardiovascular risk factor assessment

Descriptors That Increase Likelihood of Ischemia

The following descriptors suggest higher probability of ischemic origin: 1

• Pressure, squeezing, gripping, heaviness, tightness
• Retrosternal or central location
• Left-sided radiation
• Exertional or stress-related
• Dull, aching, burning quality

Descriptors That Decrease Likelihood of Ischemia

The following descriptors suggest lower probability of ischemic origin: 1, 2

• Stabbing, sharp, fleeting quality (LR 0.2-0.3)
• Pleuritic (worsens with breathing) (LR 0.2)
• Positional (changes with body position) (LR 0.3)
• Reproducible by palpation (LR 0.2-0.3)
• Right-sided or shifting location

Critical caveat: Even "low probability" descriptors do not exclude ACS and should not be used alone to discharge patients without diagnostic testing. 2, 3

Special Population Considerations

Women

Women presenting with chest pain are at high risk for underdiagnosis, and potential cardiac causes must always be considered. 1, 4

• Women are equally likely as men to present with chest pain in ACS (92% vs 91%) 1
• Emphasize accompanying symptoms more common in women with ACS: 1, 4
  • Nausea and vomiting
  • Shortness of breath
  • Jaw, neck, or shoulder pain
  • Fatigue
  • Abdominal discomfort

Common pitfall: Risk assessment tools systematically underestimate cardiac risk in women, and the term "atypical" was historically based on male presentation patterns. 4

Older Patients (≥75 years)

In patients ≥75 years of age, consider ACS when these accompanying symptoms are present: 1

• Shortness of breath
• Syncope
• Acute delirium
• Unexplained falls

Older patients account for 33% of all ACS cases but also have higher rates of alternative diagnoses, requiring more extensive workup. 1

Diverse Populations

Cultural competency training is recommended to address racial and ethnic disparities in chest pain evaluation. 1

• Use formal translation services when English is not the primary language 1
• Be aware that description and perception of chest pain may differ among diverse patient groups 1

Physical Examination Focus

Perform a focused cardiovascular examination initially to identify ACS or other life-threatening causes: 1

Life-Threatening Findings to Identify:

• ACS: Diaphoresis, tachypnea, tachycardia, hypotension, S3 gallop, new mitral regurgitation murmur 1
• Aortic dissection: Pulse differential between extremities (30% of cases), severe abrupt-onset pain, widened mediastinum 1
• Pulmonary embolism: Tachycardia + dyspnea (>90% of patients), pleuritic pain 1
• Esophageal rupture: Subcutaneous emphysema, pneumothorax, unilateral absent breath sounds 1
• Pneumothorax: Unilateral absence of breath sounds, dyspnea 1
• Pericarditis: Friction rub, pain worse in supine position 1

Benign Findings:

• Costochondritis: Tenderness of costochondral joints on palpation 1, 5
• Herpes zoster: Painful rash in dermatomal distribution 1

Important limitation: Physical examination may be completely normal in uncomplicated ACS cases. 1

Setting-Specific Recommendations

Office Setting

Unless a noncardiac cause is evident, perform an ECG for patients with stable chest pain; if unavailable, refer to the ED immediately. 1

Patients with clinical evidence of ACS or life-threatening causes should be transported urgently to the ED by EMS, not by personal vehicle. 1

Emergency Department

Acquire and review an ECG for STEMI within 10 minutes of arrival for all patients with acute chest pain. 1, 4

Measure cardiac troponin as soon as possible after presentation in all patients with suspected ACS. 1, 4

Critical pitfall: Avoid delayed transfer from office to ED for troponin testing—this causes harm and is explicitly not recommended. 1

What NOT to Use for Diagnosis

Response to nitroglycerin should NOT be used as a diagnostic criterion for cardiac ischemia. 4, 6

• Relief with nitroglycerin is not specific for cardiac causes 4
• Many noncardiac conditions respond to nitroglycerin 4

No combination of history elements alone identifies a group safe for discharge without diagnostic testing. 2, 3