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Chapter 27. Chest Pain

Sumanth D. Prabhu, MD

A 56-year-old man presents to the emergency department (ED) with a complaint of chest pain that began 60 minutes earlier and has not resolved. He states he has never had a heart attack before. He is a current smoker and has smoked 1 pack per day for 30 years. He has been having intermittent episodes of chest pain off and on for the last 4 months, but today was the first time that the chest pain persisted prompting him to visit the ED.

  • What additional questions would you ask to characterize the chest pain?
  • What associated features would suggest that chest pain is due to a serious underlying cause?
  • What associated features would indicate a benign cause for the patient's symptoms?
  • With additional history, can you reasonably determine the underlying probability of coronary artery disease in this patient?
  • Can you arrive at a diagnosis to guide further management?

Chest pain is a commonly encountered symptom in both the emergency department (ED) and the outpatient clinic, resulting from a spectrum of etiologies from minor illness to life-threatening disease. Perhaps the most pressing determination is whether chest pain is due to acute cardiac ischemia or to nonischemic cardiovascular or noncardiac causes. Each of these categories encompasses etiologies that are potentially serious. The initial evaluation, consisting of the history, physical examination, and electrocardiogram (ECG), is exceedingly important for determining the severity and acuity of the clinical presentation and for guiding the proper selection of additional diagnostic and therapeutic modalities. Of these, the history remains the cornerstone of patient assessment.

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Angina pectorisDiscomfort in the chest and/or adjacent areas (jaw, shoulder, back, arm), usually, but not always, due to myocardial ischemia.
Typical angina

Substernal chest discomfort with the following features:

  • Characteristic oppressive quality (described as "pressure," "squeezing," or "heaviness," but almost never sharp or stabbing) and duration (typically minutes).
  • Provoked by exertion or emotional stress.
  • Relieved by rest or nitroglycerin (within several minutes).

Atypical anginaChest discomfort that meets 2 of the typical angina characteristics.
Noncardiac chest painChest pain that meets 1 or none of the typical angina characteristics.
Pleuritic chest painSharp chest pain that increases with inspiration or cough.
Canadian Cardiovascular Society (CCS) Angina Classification System

Clinical grading system based on degree of limitation of ordinary physical activity:

Class I: No limitation

Class II: Slight limitation

Class III: Marked limitation

Class IV: Angina occurs with any physical activity or at rest

Myocardial infarction (MI)Prolonged severe anginal discomfort associated with myocardial necrosis.
Unstable angina (UA)Angina presenting as rest angina, severe new-onset angina (CCS class III or IV), or acceleration of previously diagnosed effort angina (to at least CCS class III).
Acute coronary syndrome (ACS)Any clinical presentation compatible with acute myocardial ischemia (encompassing MI and UA).

See Reference 1

Chest pain may arise from cardiac, noncardiac, or psychogenic causes. Cardiovascular causes may be subdivided into ischemic and nonischemic ...

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