Chest Pain History

Author: Salim Rezaie, MD
Updated: 3/28/2013

Chest Pain: Critical Elements of a Patient History

Take Home Points

Clinical factors that INCREASE likelihood of ACS/AMI:

  1. CP radiating bilaterally > right > left
  2. Diaphoresis associated with CP
  3. N/V associated with CP
  4. Pain with exertion

Clinical factors that DECREASE likelihood of ACS/AMI: Chest pain that is:

  1. Pleuritic
  2. Positional
  3. Sharp, stabbing
  4. Reproducible with palpation

Edwards et al., 2011


  • Determine any correlation between severity of CP and the risk of AMI at presentation, or composite end points (death, revascularization, or acute myocardial infarction) at 30 days
  • Severe CP was defined as 9–10 on a 10-point pain scale.

Results: (n=3,306)

  • Risk of AMI with Pain Score of 1–8 (82% of patients) = 3.0%
  • Risk of AMI with Pain Score of 9–10 (18% of patients) = 3.9%
  • Not statistically significant different

Many “atypical” symptoms are more likely to render the diagnosis of ACS than traditional “typical” symptoms

Body et al., 2010


  • Assess the value of individual symptoms for predicting a diagnosis of AMI or the occurrence of adverse events (death, AMI, revascularization via PCI or CABG) within 6 months

Results: (n=796)

  • Strongest positive predictor of AMI:
  • Diaphoresis with CP
  • Other positive predictors of AMI and adverse events
  • Nausea and vomiting with CP
  • CP with radiation to both shoulders > right shoulder > left shoulder
  • Central chest pain
  • Strongest negative predictor of AMI
  • Pain located in the left anterior chest
  • Other negative predictors of AMI and adverse events
  • CP described as pain being the same as previous AMI
  • Presence of CP at rest

No characteristics of CP alone, or in combination, identify a group of patients that can be safely discharge home without further diagnostic testing

Swap et al., 2006

Objective: In a literature review (1970-2005), identify the elements of a CP history that might be most helpful to the clinician in identifying ACS.

CP characteristics that INCREASE likelihood of ACS/MI:

Characteristic # of Patients LR
Radiating to both shoulders/arms 893 4.1
Radiating to right shoulder 770 4.7
Pain precipitated with exertion 893 2.4
Pain associated with diaphoresis 8,426 2.0

CP characteristics that DECREASE likelihood of ACS/MI:

Characteristic # of Patients LR
Pain that is sharp/stabbing 1,088 0.3
Pleuritic pain 8,822 0.2
Positional pain 8,330 0.3
Pain reproducible by palpation 8,822 0.3

NOTE: Beware the chest pain which radiates to the RIGHT shoulder (LR = 4.7).

Clinical features have a limited role in triage decision-making for ACS/AMI

Goodacre et al., 2002

Study Design: Prospective, observation cohort study

Objective: Assess the performance of clinical features used in the diagnosis of CP, specifically in patients who were clinically stable and had a non-diagnostic ECG.

Results: (n=893)

  • Predictive of ACS/AMI:
    • Exertional pain
    • Pain radiating to both arms > right arm
  • NOT predictive of ACS/AMI:
    • Presence of chest wall tenderness
    • Nausea or vomiting
    • Diaphoresis

History alone can help, but can NOT rule out ACS/AMI!

Panju et al., 1998

Objective: To identify clinical features that would increase or decrease the probability of an AMI, presenting with acute CP through a literature review (1980-1991).

Features that INCREASE the probability of an AMI

Clinical Feature LR
Chest pain that radiates to both arms 7.1
Chest pain that radiates to right shoulder 2.9

Features that DECREASE the probability of an AMI

Clinical Feature LR
Pleuritic chest pain 0.2
Chest pain that is sharp or stabbing 0.3
Positional chest pain 0.3
Chest pain reproduced by palpation 0.3


  • M. Edwards, A.M. Chang, A.C. Matsuura, M. Green, J.M. Robey, and J.E. Hollander, "Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes.", Annals of emergency medicine, 2011. [PubMed]
  • R. Body, S. Carley, C. Wibberley, G. McDowell, J. Ferguson, and K. Mackway-Jones, "The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes.", Resuscitation, 2009 [PubMed]
  • C.J. Swap, and J.T. Nagurney, "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes.", JAMA : the journal of the American Medical Association, 2005.(%20
  • S. Goodacre, T. Locker, F. Morris, and S. Campbell, "How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2002. [PubMed]
  • A.A. Panju, B.R. Hemmelgarn, G.H. Guyatt, and D.L. Simel, "The rational clinical examination. Is this patient having a myocardial infarction?", JAMA : the journal of the American Medical Association, 1998. [PubMed]
  • S.R. Pitts, R.W. Niska, J. Xu, and C.W. Burt, "National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.", National health statistics reports, 2008. [PubMed]
  • C.V. Pollack, F.D. Sites, F.S. Shofer, K.L. Sease, and J.E. Hollander, "Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2005. [PubMed]