10
Treatment
Table 1. Chest Pain Characteristics and Corresponding Causes
Nature
• Anginal symptoms are perceived as retrosternal chest discomfort (e.g., pain,
discomfort, heaviness, tightness, pressure, constriction, squeezing ) (Section 1.4.2,
Defining Chest Pain).
• Sharp chest pain that increases with inspiration and lying supine is unlikely related to
ischemic heart disease (e.g., 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 (e.g., 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 indicates ACS.
• Positional chest pain is usually nonischemic (e.g., 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.
Note: The numbering of the following tables and figures differs from that
of the Clinical Practice Guideline.
