Typical Vs Atypical Chest pain


What does typical chest pain mean? Traditionally, we thought that midsternal chest pain with radiation to left arm and increased with exertion, we just had another discussion on this topic on our grand round and all the studies and even textbooks are recommending to be careful about using these terms. The first study that I would like to mention is “Comparison of frequency of inducible myocardial ischemia in patients presenting to emergency department with typical versus atypical or nonanginal chest pain”. They enrolled 2,525 patients and they categorized patient based on (1) the presence of substernal
chest pain or (2) discomfort that was provoked by exertion or emotional stress and (3) was relieved by rest and/or nitroglycerin. Chest pain was called “typical” angina if patient had all  3-criteria and  atypical or nonanginal if less tan 3 criteria were present. You can guess now “the patients who presented with “typical” angina were no more likely to have inducible myocardial ischemia on stress testing than patients with other presenting symptoms” . so this is one reason that we have to think about using terms correctly after 40 years of using them without any evidence.
Am J Cardiol. 2010 Jun 1;105(11):1561-4.
Link to article


The second article was published in Resuscitation. “The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes” . They enrolled 796 patients, among them 148 (18.6%) was diagnosed with acute myocardial infarction. The symptoms more likely present AMI were: pain radiating to the right arm, both arms , vomiting , central chest pain and diaphoresis. Again  “the presence of rest pain or pain radiating to the left arm  did not significantly alter the probability of AMI”.
The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes.

Link to article

This is evidence based medicine. the utility of using these terms, and apply to our practice such as radiation to right arm is not cardiac or etc can be misinterpreted in patient with significant cardiac disease. Harrison’s Textbook of Internal Medicine in last edition has a guideline how to approach to acute chest discomfort. I recommend reading this chapter to all EM physicians and internal medicine and cardiologist who do not believe the aforementioned evidence!!!