Atypical Cardiac Chest Pain

We taught you what cardiac chest pain looked like, right? You remember.

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

  • 26% will experience shortness of breath as their primary complaint.
  • 23% will complain of a burning sensation similar to indigestion.
  • 6-9% will say the pain is positional or pleuritic. (Associated with respiration.)
  • 5% will describe the pain as sharp and stabbing.

And when you’re done adding up all of those atypical findings, consider this:

A full 33% of acute myocardial infarction patients will have no pain at all.

You read that right – 33%. One out of every three heart attack victims don’t feel any pain. They have syncopal episodes or they have palpitations. They may get dizzy, feel weak and even fall down. They may complain of unusual sweating or an inability to catch their breath or vague nausea. But they won’t feel pain. You’ll need to figure out that their having an acute cardiac event all on your own, without the help of the single most telltale sign in the book.

The chances of having a painless heart attack increase dramatically with age. Diabetic are particularly prone to painless MI’s and females tend to have them more often than men.

When you add it all up, the atypical chest pain patients may very well be more typical than the presentation we described in your EMT scenario. The next time you encounter an acute cardiac patient with exertional chest pain that feels like a pressure and radiates to the left arm, you may want to think to yourself, “Interesting cardiac presentation … but not very typical.”

“Symptoms Other Than Chest Pain …” Circulation, 111(24) e435-e437, 2005

“Prevalence, clinical characteristics, and mortality …”  JAMA 2000 Jun 28;283(24):3223-9

“Acute Chest Pain in The Emergency Room” Arch Intern Med. 1985;145(1):65-69


Related Articles:

Wrong Medicine

Beyond The 1-10 Pain Scale

Understanding OPQRST

Quality Assurance In EMS


  1. Great article Steve. It’s exactly what I was looking for today with the subjects I’m working on. Atypical (or, non-classic) MI presentation is one of those danger zones that can trip up a seasoned paramedic, not to mention a scripted dispatch card or EMT-Basic.

    EMT-Basics have to be able to recognize these because of the high likelihood that they will be dispatched to them through prioritized dispatch systems. They’re why I support 12-leads for EMT-Basic crews.

    Front page linked

  2. Another great article – and something that will keep me on my toes. Goes to show that not only chest pains should get an ECG Reading.
    Unfortunately we don’t have 12 leads yet on our trucks (go figure), modified chest leads it is then…

  3. Paramedic Pete says:

    Finally some evidence for what I think most of us have known for a long time. I have tried to explain this to students but I think the article does a much better job than I ever could. Can I propose that in the future the ‘classic’ signs and symptoms of AMI be called the less typical or ‘atypical’ ones. Really good article.


  1. […] what makes a good EMT (twice) and thought about what we think about our jobs. Then we addressed atypical chest pain and the meaning of the word pandemic. We even squeezed in some research on cardiac patient care […]