From the Guidelines
Chest pain during exercise can be caused by cardiac issues such as coronary artery disease, as well as non-cardiac causes like musculoskeletal pain, lung conditions, gastrointestinal issues, or anxiety, and it is crucial to seek medical attention if the pain is new, severe, or accompanied by other concerning symptoms. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, anginal symptoms are perceived as retrosternal chest discomfort, which can be triggered by physical exercise or emotional stress. The guideline also notes that sudden onset of ripping chest pain, especially in a hypertensive patient or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome.
Some key characteristics of chest pain and their corresponding causes include:
- Anginal symptoms that gradually build in intensity over a few minutes, which are likely related to ischemic heart disease
- Sharp chest pain that increases with inspiration and lying supine, which is unlikely related to ischemic heart disease
- Sudden onset of ripping chest pain, which is suspicious of an acute aortic syndrome
- Fleeting chest pain of few seconds’ duration, which is unlikely to be related to ischemic heart disease
The ACR Appropriateness Criteria for chronic chest pain with a high probability of coronary artery disease 2 also highlights the importance of considering non-ischemic cardiac and extracardiac etiologies, such as costochondritis, esophageal reflux/spasm, and myocarditis. The criteria emphasize the role of imaging in determining the presence, extent, and severity of myocardial ischemia, as well as in guiding management and determining prognosis.
In terms of management, it is essential to stop exercising immediately and seek medical attention if chest pain occurs during exercise, especially if it is new, severe, or accompanied by other concerning symptoms such as shortness of breath, nausea, or radiating pain. A medical evaluation is necessary to determine the cause of the chest pain and to guide appropriate treatment, which may include medications, lifestyle modifications, or further testing.
From the Research
Causes of Chest Pain During Exercise
Chest pain during exercise can be caused by various factors, including:
- Myocardial ischemia due to coronary microvascular dysfunction 3
- Coronary artery disease (CAD), primarily caused by atherosclerosis 4
- Myocardial infarction (MI), which may present with atypical symptoms in patients with diabetes mellitus (DM) 5
- Acute coronary syndromes (ACSs), including ST elevation myocardial infarction (STEMI) and non-ST elevation MI (NSTEMI)/unstable angina pectoris (UAP) 6
Diagnostic Considerations
Diagnosing the cause of chest pain during exercise involves:
- Obtaining an electrocardiogram (ECG) to recognize early signs of myocardial ischemia 7
- Interpreting ECG results within 10 minutes of first medical contact to identify STEMI 6
- Using high-sensitivity troponins to rapidly rule out myocardial infarction (MI) and confirm non-ST elevation MI (NSTEMI) 6
- Considering clinical suspicion of CAD despite normal initial investigations 4
Patient-Specific Factors
Patient-specific factors that may influence the presentation and diagnosis of chest pain during exercise include: