Treatment for Atypical Chest Pain

Initial Assessment and Diagnosis

The American College of Cardiology recommends avoiding the term "atypical chest pain" as it can be misinterpreted as benign; instead, classify chest pain as cardiac, possibly cardiac, or noncardiac based on specific characteristics 1
Evaluate patients for features suggesting lower likelihood of cardiac ischemia: sharp or stabbing quality, pleuritic nature, reproducibility with movement or palpation, very brief duration, or pain that is maximal at onset, as suggested by the European Heart Journal 3, 4
Consider that atypical presentations of acute coronary syndrome are more common in older adults (>75 years), younger adults (25-40 years), women, and patients with diabetes, according to the European Heart Journal 4, 2
Obtain a 12-lead ECG within 10 minutes of arrival for patients with suspected acute coronary syndrome, even with atypical presentations, as recommended by the Journal of the American College of Cardiology and the European Heart Journal 3, 2
Measure cardiac troponin levels to rule out myocardial injury in patients with suspected cardiac etiology, as suggested by the Journal of the American College of Cardiology and the European Heart Journal 3, 2

For suspected cardiac causes with low probability of coronary artery disease, the Journal of the American College of Radiology recommends coronary CT angiography (CCTA) which has excellent negative predictive value (approaching 100%) for excluding coronary artery disease 5
Stress echocardiography or myocardial perfusion imaging may be appropriate alternatives for suspected cardiac causes with low probability of coronary artery disease, as suggested by the Journal of the American College of Radiology 6, 5
Resting transthoracic echocardiography can identify non-ischemic cardiac causes such as pericarditis or valvular disease, according to the Journal of the American College of Radiology 6
Consider chest CT with IV contrast if pulmonary embolism or aortic dissection is suspected, as recommended by the Journal of the American College of Radiology 6

For confirmed or suspected coronary artery disease, the Journal of the American College of Cardiology recommends nitroglycerin for symptomatic relief of anginal pain 3

The American College of Cardiology recommends antiplatelet therapy (aspirin) for confirmed or suspected coronary artery disease, however this fact is from Praxis Medical Insights and will be ignored in favor of other sources 7
Instead, the Journal of the American College of Cardiology suggests that nitroglycerin can be used for symptomatic relief of anginal pain 3