Sumanth D. Prabhu, MD
Chest pain is a commonly encountered symptom in both the emergency department and the outpatient
clinic, resulting from a spectrum of etiologies from minor illness to life-threatening disease. Perhaps the
most pressing determination is whether chest pain is due to acute cardiac ischemia or to nonischemic
cardiovascular or noncardiac causes. Each of these categories encompasses etiologies that are potentially
serious. In view of this, the initial evaluation, consisting of the history, physical examination, and
electrocardiogram (ECG), is exceedingly important for determining the severity and acuity of the clinical
presentation, and for guiding the proper selection of additional diagnostic and therapeutic modalities. Of
these, the history remains the cornerstone of patient assessment.
Discomfort in the chest and/or adjacent areas (jaw, shoulder, back, arm),
usually, but not always, due to myocardial ischemia
Substernal chest discomfort with the following features:
Characteristic quality (described as “pressure,” “squeezing,” or
“heaviness,” but almost never sharp or stabbing) and duration
Provoked by exertion or emotional stress
Relieved by rest or nitroglycerin (within several minutes).
Chest discomfort that meets 2 of the typical angina characteristics.
Noncardiac chest pain
Chest pain that meets 1 or none of the typical angina characteristics.
Canadian Cardiovascular Society
(CCS) Angina Classification
Clinical grading system based on degree of limitation of ordinary physical
Class I: No limitation
Class II: Slight limitation
Class III: Marked limitation
Class IV: Angina occurs with any physical activity or at rest.
Myocardial infarction (MI)
Prolonged severe anginal discomfort associated with myocardial necrosis.
Pleuritic chest pain
Sharp chest pain that increases with inspiration or cough.
Unstable angina (UA)
Angina presenting as rest angina, severe new-onset angina (CCS class III or
IV), or acceleration of previously diagnosed effort angina (to at least CCS
Chest pain may arise from cardiac, noncardiac, or psychogenic causes. Cardiovascular causes may be sub-
divided into ischemic and nonischemic etiologies. Myocardial ischemia results from an imbalance
between myocardial oxygen supply and demand, such that demand exceeds supply. Ishemic chest pain or
angina is most often secondary to obstructive atherosclerotic coronary artery disease (CAD). However,
angina is also a feature of valvular heart disease (eg, aortic stenosis), severe hypertension, hypertrophic