Diagnosing chest pain symptoms is a common occurrence in the primary care setting. Approximately 1% of all visits to primary care are related to chest pain, but rarely are these visits due to an acute coronary syndrome, according to Arpit Agrawal, M.D., cardiologist with Norton Heart & Vascular Institute. Acute chest pain often needs to be evaluated immediately to rule out acute coronary syndromes, but chronic or intermittent chest pain offers several opportunities for outpatient evaluation of that pain.

“Initial workup for patients with chronic or intermittent chest pain includes a detailed history and physical and an electrocardiogram. After the initial evaluation, the provider can stratify the risk of the patient based on the quality of symptoms (typical, atypical or nonanginal pain); age; prior history of coronary disease; vascular disease; other comorbidities, including diabetes, hypertension and hyperlipidemia; and family history of coronary artery disease,” Dr. Agrawal said.

2021 Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Norton Heart & Vascular Institute Chest Pain Clinic

The Norton Heart & Vascular Institute Chest Pain Clinic offers urgent evaluation for stable patients who present with chest pain. The clinic is a three-bed outpatient unit on the Norton Audubon Hospital campus, where patients can be evaluated urgently and set up for testing, including stress testing and/or coronary CT scan.

Coronary CT allows for anatomic evaluation of the coronary arteries in a noninvasive manner, helping assess for both obstructive disease and early/nonobstructive disease that can lead to intensification of secondary prevention therapies. Coronary CT is not favored in patients with a known history of coronary artery disease/previous stents, contraindications for iodinated contrast, morbid obesity or those with irregular or difficult to control heart rates.  

Norton Heart & Vascular Institute offers the advanced CT-FFR (computed tomography–fractional flow reserve) test.  CT-FFR is a non-invasive test performed after a patient has had a coronary CT angiogram (CCTA).  With the data obtained during that study, analysis using AI algorithms and advanced computational methods creates a patient-specific 3D image of the individual’s coronary arteries.  This technology allows health care providers to more accurately assess the significance of blockages, resulting in a more precise treatment plan for the patient.  Norton Heart & Vascular Institute was the first in Louisville to offer this advanced imaging analysis to patients with suspected coronary artery disease, since early 2020.

Evaluating cardiac vs. noncardiac chest pain

Prompt and accurate diagnosis of chest pain is crucial for determining the appropriate treatment and ensuring the best possible outcomes for patients.

When evaluating chest pain, health care providers must conduct a thorough examination, considering factors such as the patient’s medical history, risk factors for coronary heart disease, the nature of the pain, associated symptoms and potential triggers.

Chest pain can be a sign of various underlying conditions ranging from noncardiac issues like musculoskeletal pain to serious cardiac conditions, such as a heart attack or unstable angina. Diagnostics may include imaging and blood tests to assess cardiac enzymes, and other tests to rule out conditions such as pulmonary embolism or aortic dissection.

Cardiac chest pain typically is caused by reduced blood flow to the heart due to a blockage in the coronary arteries, and may be associated with acute coronary syndrome conditions like unstable angina or heart attack. It usually presents as a feeling of pressure, tightness or squeezing in the chest that may radiate to the arms, neck, jaw or back. It may be triggered by physical exertion or emotional stress.

On the other hand, noncardiac chest pain is chest discomfort that is not related to the heart. It can be caused by issues like gastroesophageal reflux disease (GERD), muscle strain, inflammation in the chest wall, anxiety or a panic attack. Some noncardiac chest pain symptoms may mimic some of those of cardiac chest pain.

Immediate tests for diagnosing chest pain

Several immediate tests commonly are used to assist health care providers in diagnosing the underlying cause of chest pain promptly and accurately.

1. Electrocardiogram (ECG or EKG): Electrical activity of the heart is recorded to detect irregularities.

2. Blood tests: These tests can help assess heart damage, including levels of certain enzymes such as troponin that indicate the presence of a heart attack.

3. Chest X-ray: Images of the heart, lungs and surrounding structures may help identify chest pain causes.
4. CT scan: A computed tomography scan provides detailed images of the heart, lungs, blood vessels and more.
5. Echocardiogram: Sound waves create images of the heart’s structure and function.

If patients are at high risk for coronary heart disease, they should be referred to cardiology to discuss invasive versus noninvasive evaluation. For those who are at intermediate risk for coronary heart disease and additional testing is warranted, patients can be referred for risk stratification with either coronary CT or stress testing. 

Reviewed by Arpit Agrawal, M.D., cardiologist with Norton Heart & Vascular Institute