Cold Air-Induced Chest Pain in High-Risk Populations

Mechanisms and Risk Stratification

The American College of Cardiology recommends that patients with pre-existing cardiac disease, such as ischemic heart disease, should be evaluated for acute coronary syndrome if they experience cold-related chest pain, as physical exercise or emotional stress, including cold stress, are common triggers of anginal symptoms 1, 2
The British Thoracic Society recognizes that patients with respiratory disease may experience chest pain during air travel due to hypoxemia, a similar physiological stress to cold exposure, and young adults with current asthma have an increased risk of cold-related chest pain 3, 4

The American College of Cardiology recommends performing a focused cardiovascular examination initially to identify potentially serious causes of chest pain, such as acute coronary syndrome, aortic dissection, pulmonary embolism, and pericarditis 6, 5
Acute coronary syndrome should be suspected in patients with diaphoresis, tachycardia, hypotension, or pain radiating to the left arm/jaw, and immediate ECG and cardiac biomarkers are warranted 1, 6, 5
Aortic dissection should be suspected in patients with sudden onset of severe "ripping" pain, especially with pulse differential or radiation to the back, and emergent imaging is required 1, 2, 7
Pulmonary embolism should be suspected in patients with tachycardia and dyspnea, and pleuritic chest pain with dyspnea demands evaluation 6
Pericarditis should be suspected in patients with sharp chest pain that increases with inspiration and lying supine, potentially with friction rub 1, 2, 7

The American College of Cardiology emphasizes that women are at particular risk for underdiagnosis of cardiac disease, and patients with cardiovascular risk factors should not have their chest pain in cold weather dismissed as benign without proper evaluation 1, 2, 7
Older patients (>75 years) may present with atypical symptoms, including isolated dyspnea or confusion, and require careful evaluation 2, 7
Patients with diabetes may have atypical presentations of cardiac ischemia, and a high index of suspicion is necessary 1, 8