Atypical Chest Pain

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”¹

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Physicians often act like Humpty Dumpty. We use words to mean just what we choose them to mean and assume that everybody knows exactly what we mean when we use them. A typical example is “atypical chest pain,” a term that commonly crops up in patients' records, teaching conferences, medical literature, and conversations held in health care clinics, doctors' offices, and emergency departments. But what does “atypical chest pain” mean?

In 1986, I tried to answer that question.² First, I went to the medical library, but the information that I found there was inconclusive and confusing. Some authors used “atypical” in reference to clinical features that were atypical of angina pectoris.^3–6 Others considered chest pain to be atypical when its distribution was unusual or its precipitating and relieving factors were unusual; in such cases, esophageal disorders were the most frequently identified cause of the pain.⁷ Several reports mentioned atypical chest pain but didn't define it,^8,9 while one review of chest pain didn't mention the term at all.¹⁰

Dissatisfied with my search for clarity, I decided to determine what “atypical chest pain” meant to 50 physicians—25 practicing internists and 25 internal medicine house officers. Roughly half of the group believed that the term meant pain that was atypical of angina pectoris. Almost as many thought that it meant pain of unknown cause. One person labeled the term meaningless, and a few confessed to using it in order to admit a patient to the hospital, thereby postponing further thought. Two physicians said that they diagnosed “atypical chest pain” when they wanted to persuade a consultant to assume the patient's care or to perform a special procedure such as esophagoscopy or cardiac catheterization.

Today, 23 years later, “atypical chest pain” is still popular in medical circles. Its meaning, however, remains unclear. A few articles have the term in their title, but do not define or discuss it in their text.^11,12 In other articles, the term refers to noncardiac causes of chest pain.^13–15 One recent review defines it as “chest pain not caused by myocardial ischemia,”¹⁶ while another simply recommends avoiding the term.¹⁷ And one brief report concludes: “What do we really mean by atypical chest pain? In reality we don't mean anything.”¹⁸

Whether chest pain is typical or not depends primarily on one's perception of “typical.” Such perception, in turn, depends on one's depth of medical knowledge and the time spent evaluating the patient. Remember that in the individual case, manifestations of any disease fall somewhere on a bell-shaped curve. Unless we are familiar with the manifestations at either end of the curve, we will interpret them as atypical even though they are, in fact, typical. Stated another way, the pain may be truly atypical of the condition we are thinking of (for example, angina pectoris) but clearly typical of one we aren't thinking of (pericardial fat pad necrosis). Furthermore, in the zeal to prove our initial impression, we may set in motion a “fruitless search for infallibility,”¹⁹ resulting in a host of ill-directed, expensive, time-consuming, and sometimes dangerous studies.

Delivering good health care these days is hard enough without using Humpty Dumpty terminology. Instead of “atypical chest pain,” I recommend substituting “chest pain, ? cause”²⁰ or “unexplained chest pain.” Doing so would reduce the risk of miscommunication, remind us of our ignorance, stimulate us to think, and keep us honest with ourselves and our patients.

In conclusion:

“Atypical chest pain” sits up on a wall, “Atypical chest pain” deserves a big fall, Let's strive for specificity and clarity of thought, And abandon the term, as surely we ought.

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