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Classic coronary pain--or angina--involves a substernal pressure that commonly begins with exertion and is relieved by rest. However, some patients experience angina in the absence of physical exertion or emotional stress, and not all chest pain that begins after exertion is angina. Atypical chest pain must be differentiated from other types of chest pain, including chest wall pain, pleurisy, gallbladder pain, hiatal hernia, and chest pain associated with anxiety disorders. Careful examination of the chest wall is essential, and abnormal heart sounds can tell you a great deal. Further testing is individualized. An exercise ECG is important in identifying the presence of ischemic heart disease and the amount of myocardium at risk. If the ECG is abnormal at rest, the patient should undergo a thallium stress test or exercise echocardiography. A coronary angiogram is indicated if the exercise test or an ECG during pain show that a lot of live heart muscle is at risk.

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