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The diagnosis of nonanginal chest pain
1Department of Internal Medicine, State University of New York, Buffalo 14216.
Insights
Distinguishing nonanginal chest pain from atypical angina avoids unnecessary coronary angiography. Key indicators include pain duration, positional changes, and specific triggers, helping rule out cardiac causes.
Area of Science:
- Cardiology
- Diagnostic Medicine
Background:
- The term "atypical chest pain" is often a vague diagnosis, leading to overuse of invasive coronary angiography.
- Accurate differentiation between nonanginal chest pain and angina is crucial to prevent unnecessary procedures.
Purpose of the Study:
- To define clinical features that reliably distinguish nonanginal chest pain from angina.
- To guide physicians in avoiding unnecessary coronary angiography by identifying nonanginal chest pain.
Main Methods:
- Analysis of chest pain characteristics, including duration, triggers, and relieving factors.
- Identification of presumptive signs suggestive of nonanginal chest pain.
- Comparison with conditions mimicking angina, such as cervical root compression and esophageal spasm.
Main Results:
- Nonanginal chest pain is suggested by durations over 30 minutes or under 5 seconds, increase with inspiration, or provocation by trunk movement or local pressure.
- Specific signs like one-finger localization, nuchal radiation, inframammary site, sudden onset, or relief with swallowing indicate nonanginal pain.
- Cervical root compression and esophageal spasm can mimic angina but possess distinguishing features.
Conclusions:
- Physicians can differentiate nonanginal chest pain from angina by assessing specific clinical features.
- This differentiation can significantly reduce the need for unnecessary invasive coronary angiography.
Abstract:
The term "atypical chest pain" is a waste-basket term that leads physicians to send any patient with chest pain to coronary angiography. In order to avoid this term, we must learn to distinguish atypical angina from nonanginal chest pain before angiography is considered in order to avoid unnecessary invasive procedures. A chest pain is very likely nonanginal if its duration is over 30 minutes or less than 5 seconds, it increases with inspiration, can be brought on with one movement of the trunk or arm, can be brought on by local fingers pressure, or bending forward, or it can be relieved immediately on lying down. There are also many presumptive signs of nonanginal chest pain such as localization with one finger, radiation to the nuchal area, an inframammary primary site, a pain that reaches maximum at the onset, or relief within a few seconds of swallowing food. Cervical root compression pain and esophageal spasm are the greatest mimics of angina since they can both be relieved by nitroglycerin but they have several features which help to rule out angina.