Chest pain classification

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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 Anginal symptoms are defining as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing 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 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. 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 ( aortic dissection)
Precipitating factors 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 Positional chest pain usually indicates nonischemic (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 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.

The above table adopted from 2021 AHA/ACC/ASE Guideline