Guideline for the Evaluation and Diagnosis of Chest Pain

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain.

Defining Chest 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.

Chest pain should be considered acute when it is new onset or involves a change in pattern, intensity, or duration compared with previous episodes in a patient with recurrent symptoms. Chest pain should be considered stable when symptoms are chronic and associated with consistent precipitants such as exertion or emotional stress.

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.”

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

Despite individual variability, the discomfort induced by myocardial ischemia is often characteristic and therefore central to the diagnosis. For this reason, features more likely to be associated with ischemia have been described as typical versus atypical.

Recommendation

Figure 1. Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors

Chest Pain Characteristics and Corresponding Causes

A comprehensive history that captures all the characteristics of chest pain, including but not limited to its: 1) nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients.

Like most visceral discomfort, the sensation produced by myocardial ischemia is characteristically deep, difficult to localize, and usually diffuse. Point tenderness renders ischemia less likely.

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

It is essential to ascertain the characteristics of the chest pain directly from the patient for optimal interpretation. A patient’s history is the most important basis for considering presence or absence of myocardial ischemia. The diagnosis of ischemia may require data beyond history alone.

Chest pain has been traditionally stratified into “typical” and “atypical” types. Chest pain that is more likely associated with ischemia consists of substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin.

The more classic the chest discomfort is based on quality, location, radiation, and provoking and relieving factors, the more likely it is to be of cardiac ischemic origin.

Atypical chest pain is 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, it has discouraged the use of atypical chest pain.

Of note, chest pain is broadly defined to also include referred pain in the shoulders, arms, jaw, neck, and upper abdomen.

To diminish ambiguity, use “cardiac,” “possible cardiac,” and “noncardiac” to describe the suspected cause of chest pain is encouraged.

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Nature

Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing).

Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (eg, these symptoms usually occur with acute pericarditis).

Onset and duration

Anginal symptoms gradually build in intensity over a few minutes.

Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome.

Fleeting chest pain—of few seconds’ duration—is unlikely to be related to ischemic heart disease.

Location and radiation

Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.

Severity

Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg, aortic dissection).

Precipitating factors

Physical exercise or emotional stresses are common triggers of anginal symptoms.

Occurrence at rest or with minimal exertion associated with anginal symptoms usually indicates ACS.

Positional chest pain is usually nonischemic (eg, musculoskeletal).

Relieving factors

Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.

Associated symptoms

Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting.

Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or abdomen may occur in patients with diabetes, women, and elderly patients.