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,

-ACP

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5 thoughts on “Cardiac Chest Pain: Importance of the Patient’s History”

  1. Thank you Dr. Pearson, you were definitely a part of my inspiration to go for it!

    I was watching a presentation about chest pain in the ER setting a few months ago and it was interesting. The focus was centered on the one and done test to rule out MI (just doing one ecg and one troponin) instead of serial ecgs and troponins to get a better idea if there were changes that could indicate an event. The speaker cited several examples where hospitals were sued b/c the provider did not meet the standard of care. This in itself was an interesting topic because in many hospitals and groups there were no set in stone “standards of care” but depended heavily on the clinical judgement of the HCP caring for the patient.

    On the flip side, as you have mentioned many times differentiating from benign (no further testing) to concerning (more testing) is an art that can be guided by guidelines but still requires significant expertise. The “safe or thorough” approach of doing a stress test or CCTA is often not so safe because that information in the hands of an inexperienced HCP can be the start of more invasive testing and procedures (often unneeded and potentially detrimental to the patient). I have a tremendous amount of respect for HCPs that can do the limbo of doing just enough to get a reliable diagnosis but not too much or too little testing to get that diagnosis.

    I am looking forward to reading your take on how you handle chest pain, and to see how it compares to the guidelines. In your opinion do you feel most clinicians are guided by an algorithm to test/not test further or do you think much of it is still discretionary and based on clinical experience? I know you think more is NOT better in regards to diagnostics but have you always felt this way or did your thoughts evolve like your beliefs on dairy fat and diet?

    A question related to chest pain tests, I have seen in the literature the use of the terms troponins, hs-cTn and and hs-cTnI and hs-cTnT, do you have any guidance on what most hospitals/cardiologist use and is there one more reliable than the other?

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  2. In my very limited clinical experience most patients on the floor who have chest pain that is not relieved by positional change get an ECG. I have never worked in an ER environment except for a brief period and my observation was that patients that presented with chest pain where there was no obvious trauma were evaluated initially by ECG and trops and then sometimes CBC,CMP/BMP.

    I was curious though, I have read that sometimes you can auscultate a 4th heart sound that might indicate the early stages of an acute MI. I thought this was interesting yet in more reading realized that there are many etiologies of this namely LV hypertrophy, ischemia or anything that affects the compliance of the left ventricle can cause this sound to be heard. Based on the further reading and limited knowledge of other diagnostic tools in the toolbox, auscultation by stethoscope did not seem to have the sensitivity to be of much use in determining whether chest pain is the result of an active MI.

    Although probably not the best tool for chest pain, it has given me a renewed interest in using my stethoscope to its full potential. For the most part I find it useful mainly for lung sounds (which could indicate right or left sided HF) but many other things as well unrelated to the heart. I did hear my first murmur a few weeks ago (on my own) and confirmed this by my patients chart, however I want to learn more. As cardiologists I have heard folklore about your specialty having jedi like powers with your stethoscopes. Do you find the stethoscope still a valuable tool in the modern cardiology world? How long did it take you to feel comfortable using it as a reliable diagnostic tool? What kind of stethoscope do you feel yields the best results in hearing heart sounds?

    Reply
    • Christian,
      Congratulation on gaining clinical skills!
      Some very early studies I and my colleagues performed in conjunction with the legendary Mort Kern in the Cath lab showed that within 30 seconds after occluding a coronary artery there are changes in the diastolic filling pattern that increase the atrial contribution to filling. Any process that increases atrial filling can result in an increased S4. Alas, this has very limited specificity for acute MI and in general the S4 is difficult to appreciates so no clinical utility.
      If a patient with MI has developed heart failure then we might hear an S3 or pulmonary rales but these are not specific to MI.
      Rare patients with MI develop severe mitral regurgitation from a ruptured papillary muscle which typically would cause an apical holosystolic murmur. This is usually not in the acute phase but a few days later. Same with ventricular septal rupture which is rare these days but I saw one at SLU in October with a great systolic murmur.
      The stethoscope has value but the widespread availability of echo has diminished its value steadily. I prefer the Littman Cardiology Stethoscope. I found no value BTW in the EKO stethoscopes.
      In my experience I can hear murmurs that non cardiologists struggle with, even if I hold the stethoscope on the site on the chest where I heard the murmur.
      Dr P

      Reply
  3. Dear skeptical doc: high-sensitivity troponin can be considered an improvement in CAD diagnosis only if false positives are considered much less important than true positives. And if the emotional scar that remains after you say: “cheer up, we said you had a heart attack but you didn´t” is considered a minor side efffect.

    Reply
  4. This is a timely article for me. I have been experiencing chest pain off and on for the last 6 years or so. Since I had a heart attack 21 years ago my cardiologist always recommends I get it checked out…better safe than sorry. I have made 3 trips to the ER, always with negative MI results. The pain has been getting worse in the last year or so, often enough to affect my quality of life. Vacation plans cancelled! Have had ultrasound, echocardiogram, endoscopy and CT scan. All normal. Exercise tolerance is good. I have a pectus excavatum deformity but it is mild, 2.7. 9 years ago had a traumatic chest injury from motor vehicle accident which resulted in multiple broken ribs, collapsed lung and chest surgery. The best guess from chest surgeon is chest wall syndrome/costochondritis. I have started physical therapy along with anti-inflammatory drugs and am doing much better. Fingers crossed. When your chest is killing you its easy to convince yourself your having another heart attack. I’m 62.

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