Typical and atypical chest pain: an equivocal and dangerous definition

Abstract

Abstract Background The traditional classification of stable chest pain into typical, atypical and non anginal1 is equivocal and can lead to doctor's decisions and patient's perception that do not correspond to the real importance of the clinical picture. Methods In the last 15 years, 3,588 outpatients, aged >35 years (mean 64±9, female 55%) were evaluated for stable chest pain reported for more than 48 hours. We excluded 290 patients with a history of myocardial infarction or angina pectoris, heart failure, valve diseases or any other major cardiovascular event, or ECG signs of recent ischemia. In the other 3,298 cases we applied the traditional classification of chest pain. All patients were evaluated for the presence of HEART score risk factors² (smoking, obesity, family history of cardiovascular events, hypertension, diabetes, hypercholesterolemia) as well as age. All patients with typical or atypical angina and those with non-anginal pain according to the physician's judgment were evaluated with one or more functional cardiovascular tests (exertion test, nuclear stress tests, stress echo).A follow-up was performed at 6 months and 1 year, for the detection of major cardiovascular events (cardiovascular death, non-fatal heart attack, revascularization, stroke) and non-cardiovascular mortality. Results Table 1 shows the results of chest pain classification and positive functional test. Table 2 shows major events at one year of follow-up stratified according to the initial assessment of chest pain. Table 3 stratifies the events according to the extent of the risk factors and age. It is evident that a positive functional test is also present in 10% of patients with atypical pain and in 4% of those with non-anginal pain. Patients with typical pain undergo revascularization more frequently (39%). The peculiarity of our study is that the prognosis and rate of events do not differ in terms of clinical and ischemic burden among the 3 groups at 1 year of follow-up, except when patients are stratified by risk burden and for age (Table 4). About 1% of patients had a clinical event regardless of the type of pain and the presence of ischemia and 87% of the events involved patients with ≥ 3 risk factors or heavy smokers. Nine percent of all heavy smokers aged <65 years had a major event and are the highest risk group with a peak of 12.5% in those with atypical pain. Conclusions The traditional classification of stable chest pain should be abandoned, as it does not correlate with actual disease burden and prognosis, that appears to be linked to the burden of cardiovascular risk and above all to smoking in patients < 65 years of age, rather than to the clinical and ischemic burden. It will be necessary to evaluate whether the anatomical burden for the search of high-risk coronary lesions improves the prognosis with added value with respect to the treatment of risk factors³.Picture 1Picture 2