Chest pain classification: Difference between revisions
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{{CMG}}; {{AE}} {{Sara.Zand}} {{Aisha}} | {{CMG}}; {{AE}} {{Sara.Zand}} {{Aisha}} | ||
==Overview== | ==Overview== | ||
[[Chest pain]] traditionally has been classified into [[typical]] and atypical types. [[Chest pain]] that is more likely associated with [[ischemia]] | [[Chest pain]] traditionally has been classified into [[typical]] and atypical types. [[Chest pain]] that is more likely associated with [[ischemia]] includes of substernal [[chest discomfort]] aggravated by [[exertion]] or [[emotional stress]] and relieved by [[rest]] or [[nitroglycerin]]. [[Ischemic chest discomfort]] can be described based on [[quality]], [[location]], [[radiation]], and provoking and relieving factors. Using the term of [[atypical chest pain]] is problematic. Although the term of atypical [[chest pain]] was intended to describe [[angina]] without typical [[chest]] [[symptoms]], it is more often used to consider that the [[symptom]] is [[noncardiac]] in origin. Then, based upon the [[ACC/AHA Guideline]] 2021, it is discouraged to use the term of atypical [[chest pain]]. Notably, [[chest pain]] is a broadly term to define referred [[pain]] in the [[shoulders]], [[arms]], [[jaw]], [[neck]], and upper [[abdomen]]. So, using the terms of [[cardiac]], possible [[cardiac]], and [[noncardiac]] are encouraged to describe the nature of [[chest pain]]. | ||
==Classification== | ==Classification== | ||
[[Chest pain ]] is classified into three subgroups including [[cardiac]], possible [[cardiac]], and [[noncardiac]]. | |||
* Non-cardiac [[chest pain]] is used when the etiology of [[chest pain]] is not related to [[heart]]. | * Non-cardiac [[chest pain]] is used when the etiology of [[chest pain]] is not related to the [[heart]]. | ||
* The term of Non-cardiac [[chest pain]] is encouraged to use instead of atypical [[chest pain]], because atypical [[chest pain]] is a misleading description | * The term of Non-cardiac [[chest pain]] is encouraged to use instead of atypical [[chest pain]], because atypical [[chest pain]] is a misleading description. | ||
* Cardiac [[chest Pain]] means more | * Cardiac [[chest Pain]] means more than pain in the [[Chest]]. It can also mean [[pressure]], [[tightness]], or [[discomfort]] in the [[chest]], [[shoulders]], [[arms]], [[neck]], [[ back]], upper [[abdomen]], or [[jaw]], as well as [[shortness of breath]] and [[fatigue]], should all be considered [[anginal]] equivalents. | ||
*The current classification system that is endorsed by ACC/AHA 2021 is shown below: | |||
{| style="width:75%; height:200px" border="1" | |||
|- | |||
| [[Cardiac]] || The initial assessment should be focused on investigation about [[myocardial ischemia]] | |||
|- style="height:100px" | |||
| Non-[[cardiac]] || The term of [[atypical chest pain]] should not be used, because of misinterpretation of [[cardiac ]] [[chest pain]] as benign in nature | |||
|- | |||
| Possible cardiac || | |||
|- | |||
| Acute [[chest pain]] || New onset, or change in pattern, intensity, duration of [[chest pain]] compared with prior episode | |||
|- style="height:100px" | |||
| Stable [[chest pain]]|| Chronic [[symptoms]] , worsening with [[exertional]] or [[emotional stress]] | |||
|} | |||
Characteristics of cardiac chest pain: | |||
{| style="border: 2px solid #4479BA; align="left" | {| style="border: 2px solid #4479BA; align="left" | ||
! style="width: | ! style="width: 1000px; background: #4479BA;" | {{fontcolor|#FFF|Chest pain characteristics and corresponding causes}} | ||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Nature]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Nature]] | ||
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*Sharp [[chest pain]] that increases with [[inspiration]] and lying [[supine]] usually occur with acute [[pericarditis]] and is unlikely related to [[ischemic heart disease]] | *Sharp [[chest pain]] that increases with [[inspiration]] and lying [[supine]] usually occur with acute [[pericarditis]] and is unlikely related to [[ischemic heart disease]] | ||
|- | |- | ||
|Onset and [[duration]] | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Onset and [[duration]] | ||
*[[Anginal symptoms]] gradually increase in intensity over a few minutes | *[[Anginal symptoms]] gradually increase in intensity over a few minutes | ||
*Sudden onset of ripping [[chest pain]] (with radiation to the upper or lower [[back]]) is suspicious of an acute [[aortic syndrome]] and is unlikely to be [[anginal]]. | *Sudden onset of ripping [[chest pain]] (with radiation to the upper or lower [[back]]) is suspicious of an acute [[aortic syndrome]] and is unlikely to be [[anginal]]. | ||
*Fleeting [[chest pain]]—of few seconds’ duration—is unlikely to be related to [[ischemic heart disease]]. | *Fleeting [[chest pain]]—of few seconds’ duration—is unlikely to be related to [[ischemic heart disease]]. | ||
|- | |- | ||
|[[Location]] and [[radiation]] | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[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]]. | *[[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]] | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[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]] ( [[aortic dissection]]) | *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]] ( [[aortic dissection]]) | ||
|- | |- | ||
|[[Precipitating]] factors | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Precipitating]] factors | ||
*[[Physical exercise]] or [[emotional stress]] are Common triggers of [[anginal]] [[symptoms]] | *[[Physical exercise]] or [[emotional stress]] are Common triggers of [[anginal]] [[symptoms]] | ||
*Occurrence at [[rest]] or with minimal [[exertion]] associated with [[anginal symptoms]] usually aoociated with [[ACS]] | *Occurrence at [[rest]] or with minimal [[exertion]] associated with [[anginal symptoms]] usually aoociated with [[ACS]] | ||
*[[Positional]] [[ chest pain]] usually indicates [[nonischemic]] ([[ musculoskeletal]]) | *[[Positional]] [[ chest pain]] usually indicates [[nonischemic]] ([[ musculoskeletal]]) | ||
|- | |- | ||
|[[Relieving]] factors | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Relieving]] factors | ||
*Relief with [[nitroglycerin]] is not necessarily diagnostic of [[myocardial ischemia]] and should not be used as a diagnostic [[criterion]]. | *Relief with [[nitroglycerin]] is not necessarily diagnostic of [[myocardial ischemia]] and should not be used as a diagnostic [[criterion]]. | ||
|- | |- | ||
|Associated [[symptoms]] | |style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Associated [[symptoms]] | ||
*Common [[symptoms]] associated with [[myocardial ischemia]] including [[dyspnea]], [[palpitations]], [[diaphoresis]], [[lightheadedness]], [[presyncope]] or [[syncope]], upper [[abdominal pain]], or [[heartburn]] unrelated to [[meals]] and [[nausea]] or [[vomiting]] | *Common [[symptoms]] associated with [[myocardial ischemia]] including [[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]]. | *[[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]]. | ||
|} | |} | ||
{| | {| | ||
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC/ASE Guideline<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref> | ! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC/ASE Guideline<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref> | ||
Latest revision as of 06:35, 6 May 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]
Overview
Chest pain traditionally has been classified into typical and atypical types. Chest pain that is more likely associated with ischemia includes of substernal chest discomfort aggravated by exertion or emotional stress and relieved by rest or nitroglycerin. Ischemic chest discomfort can be described based on quality, location, radiation, and provoking and relieving factors. Using the term of atypical chest pain is problematic. Although the term of atypical chest pain was intended to describe angina without typical chest symptoms, it is more often used to consider that the symptom is noncardiac in origin. Then, based upon the ACC/AHA Guideline 2021, it is discouraged to use the term of atypical chest pain. Notably, chest pain is a broadly term to define referred pain in the shoulders, arms, jaw, neck, and upper abdomen. So, using the terms of cardiac, possible cardiac, and noncardiac are encouraged to describe the nature of chest pain.
Classification
Chest pain is classified into three subgroups including cardiac, possible cardiac, and noncardiac.
- Non-cardiac chest pain is used when the etiology of chest pain is not related to the heart.
- The term of Non-cardiac chest pain is encouraged to use instead of atypical chest pain, because atypical chest pain is a misleading description.
- Cardiac chest Pain means more than pain in the Chest. It can also mean pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, should all be considered anginal equivalents.
- The current classification system that is endorsed by ACC/AHA 2021 is shown below:
| Cardiac | The initial assessment should be focused on investigation about myocardial ischemia |
| Non-cardiac | The term of atypical chest pain should not be used, because of misinterpretation of cardiac chest pain as benign in nature |
| Possible cardiac | |
| Acute chest pain | New onset, or change in pattern, intensity, duration of chest pain compared with prior episode |
| Stable chest pain | Chronic symptoms , worsening with exertional or emotional stress |
Characteristics of cardiac chest pain:
| Chest pain characteristics and corresponding causes |
|---|
Nature
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Onset and duration
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Location and radiation
|
Severity
|
Precipitating factors
|
Relieving factors
|
Associated symptoms
|
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
|---|
References
- ↑ Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check
|pmid=value (help).