From the Guidelines
Atypical chest pain should be referred to as "noncardiac" if heart disease is not suspected, as the term "atypical" is no longer preferred in the evaluation and diagnosis of chest pain, according to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. When evaluating chest pain, it's essential to consider that pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, should all be considered anginal equivalents, as stated in the guideline 1. Key differences between typical and noncardiac chest pain include:
- Typical chest pain is often associated with cardiac issues and presents as a pressure, squeezing, or heaviness in the center or left side of the chest
- Noncardiac chest pain may be sharp, stabbing, or burning; localized to a small area; change with position or breathing; last for seconds or hours; and not respond to cardiac medications
- Noncardiac chest pain often stems from non-cardiac causes like musculoskeletal issues, gastrointestinal problems (GERD, esophageal spasm), pulmonary conditions, or anxiety However, it's crucial to note that some patients, such as women, elderly patients, and those with diabetes, may present with noncardiac symptoms even during actual cardiac events, highlighting the importance of careful evaluation and consideration of individual patient characteristics, as emphasized in the guideline 1. In terms of evaluation and diagnosis, 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. Additionally, clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely to guide appropriate diagnostic testing and treatment, potentially saving lives in cases of actual cardiac emergencies 1.
From the Research
Atypical Chest Pain vs Typical Chest Pain
- Atypical chest pain refers to chest pain that does not exhibit the typical characteristics of acute coronary syndrome (ACS), such as chest pressure or tightness radiating to the arm, neck, or jaw 2.
- Typical chest pain, on the other hand, is characterized by chest pressure or tightness, often accompanied by other symptoms such as shortness of breath, nausea, or fatigue 3.
- The evaluation of patients with acute chest pain, whether typical or atypical, involves a thorough clinical investigation, including medical history, physical examination, electrocardiogram (ECG), and further focused diagnostics 4.
Diagnostic Approaches
- For patients with suspected ACS, risk stratification scores such as the TIMI or HEART score can be used to determine the likelihood of coronary artery disease (CAD) 2.
- Imaging modalities such as coronary computed tomography angiography (CTA) and stress echocardiography (SE) can also be used to evaluate patients with acute chest pain 3, 5.
- A study comparing CTA and SE found that SE resulted in a smaller proportion of patients being hospitalized with a shorter length of stay, and was safe 5.
- Another study found that exercise stress echocardiography (ex-Echo) had higher accuracy and specificity than exercise stress-perfusion nuclear imaging (ex-SPECT) for diagnosing CAD in patients with low-risk chest pain 6.
Challenges and Limitations
- The diagnosis of ACS can be challenging, and many patients are misdiagnosed or inappropriately discharged from the emergency department 2.
- The use of risk stratification scores and imaging modalities can help improve diagnostic accuracy, but there may be limitations and variability in their application 3, 4.
- Further research is needed to optimize the evaluation and management of patients with acute chest pain, particularly those with atypical symptoms 3, 5.