The Skeptical Cardiologist

Cardiac Chest Pain: Importance of the Patient’s History

Chest pain is often the key manifestation of serious cardiac disease but many noncardiac conditions cause chest pain. The medical term for the symptom that patients feel when the heart is not getting enough oxygen (typically due to a blocked coronary artery, thus caused by coronary or myocardial ischemia) is angina pectoris which derives from the Latin words angere (to choke or throttle/strangle) and pectus (chest.)

To sort out benign from malignant causes of chest pain, the most important initial step is to take a detailed history.

For the first time ever, the ACC and AHA have published a guideline focused on the evaluation and diagnosis of chest pain. The skeptical cardiologist was pleased to see that it begins with a focus on the elements of the patient’s history or narrative description of the pain:

A patient’s history is the most important basis for considering presence or absence of myocardial ischemia, but the source of cardiac symptoms is complex, and their expression is variable…Like most visceral discomfort, the sensation produced by myocardial ischemia is characteristically deep, difficult to localize, and usually diffuse.

The authors appropriately note we must be vigilant to patient descriptions other than “pain:”

The term “chest pain” is used by patients and applied by clinicians to describe the many unpleasant or uncomfortable sensations in the anterior chest that prompt concern for a cardiac problem…..Although the term chest pain is used in clinical practice, patients often report pressure, tightness, squeezing, heaviness, or burning. In this regard, a more appropriate term is “chest discomfort,” because patients may not use the descriptor “pain.”

This is a critically important point and I have had numerous patients with angina from coronary artery disease answer no when asked if they have any chest pain when exerting themselves but subsequently reveal they do have a pressure or burning sensation that comes on when they climb hills and goes away after 5 minutes of rest.

Thus, when asking patients about symptoms, I do use the phrase “chest discomfort” but also add burning, squeezing, or heaviness.

Typical Symptoms

The location of the chest discomfort in patients with symptomatic myocardial ischemia is not always in the anterior chest or over the left breast region

They may also report a location other than the chest, including the shoulder, arm, neck, back, upper abdomen, or jaw. 

If a patient tells me they get right arm squeezing sensation whenever they climb the basement stairs that is worrisome for angina.

Clearly, I am much for concerned about discomfort that comes on with exertion and goes away with rest within 5-10 minutes

Other clinical elements (e.g., duration, provoking and relieving factors, patient age, cardiac risk factors) provide further focus toward or away from ischemia in the diagnostic process.

Atypical Symptoms

There are “atypical” presentations of angina but as the authors write

Although other nonclassic symptoms of ischemia, such as shortness of breath, nausea, radiating discomfort, or numbness, may be present, chest pain or chest discomfort remains the predominant symptom reported in men and women who are ultimately diagnosed with myocardial ischemia

Sometimes, especially in diabetics, shortness of breath on exertion is the only symptom of coronary ischemia.

Certain descriptors of chest pain make it almost certain that we are not dealing with a cardiac cause. If the pain only occurs with coughing or inspiration it is not angina. If a certain position brings it on it is not angina.

Pain—described as sharp, fleeting, related to inspiration (pleuritic) or position, or shifting locations—suggests a lower likelihood of ischemia.

There is a nice figure accompanying the text which puts all the various characteristics into a graphic form. Truly, the probability that we are dealing with true coronary ischemia as a cause of our patients’ chest pain does exist on this kind of a continuum and the diagnosis is not “black and white.”

Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors

Atypical Chest Pain Now Considered Problematic

The authors find “atypical chest pain” to be a “problematic term.”

Although it was intended to indicate angina without typical chest symptoms, it is more often used to state that the symptom is noncardiac in origin. As such, we discourage the use of atypical chest pain. Emphasis is more constructively placed on specific aspects of symptoms that suggest their origin in terms of probable ischemia. To diminish ambiguity, use “cardiac,” “possible cardiac,” and “n oncardiac” to describe the suspected cause of chest pain is encouraged.

I am somewhat in agreement with this semantic discussion. For patients who have symptoms in the green/low probability area of the continuum, I use the term noncardiac chest pain. For those with typical symptoms in the red/high probability area, I use the term angina.

For patients who have some descriptors that are red and some green (which is not uncommon) I often use the phrase “chest pain with typical and atypical features.” This makes them intermediate probability and possibly cardiac in origin.

In a post from 2015 entitled “I’m having chest pain, is it a heart attack” I use the term atypical angina and describe in more detail the factors to consider when you are trying to determine if your chest pain could be a myocardial infarction.

The new chest pain guidelines have 10 take-home points which are summarized in this colorful but mostly useless graphic seemingly aimed at children:

One of the key questions for clinicians is what diagnostic test to begin with for the office patient with chest pain. I have my own approach which emphasizes noninvasive testing for stable chest pain. We’ll see how the guidelines compare to this in subsequent posts.

Antianginally Yours,


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