Last reviewed: June 2020
Last updated: September  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • increasing frequency of chest pain
  • increasing severity of chest pain
  • retrosternal chest pain radiating to jaw, arm, or neck
  • dyspnoea
  • fourth heart sound (S4)

Other diagnostic factors

  • atypical chest discomfort
  • diaphoresis
  • nausea
  • tachycardia
  • carotid bruit
  • poor peripheral pulses
  • syncope
  • third heart sound (S3)
  • murmur
  • rales

Risk factors

  • female sex
  • personal history of coronary artery disease (CAD)
  • increased age
  • family history of CAD
  • hypertension
  • smoking
  • diabetes mellitus
  • hyperlipidaemia
  • peripheral vascular disease
  • obesity/lack of exercise
  • chronic kidney disease
  • elevated C-reactive protein (CRP) levels
  • mediastinal radiation
  • high altitude

Diagnostic investigations

1st investigations to order

  • ECG
  • cardiac biomarkers
  • FBC
  • electrolytes and renal function
  • blood sugar
  • lipid profile
  • coagulation profile
  • CXR
  • echo: rest
  • myocardial perfusion study: rest
  • CT chest or MRI
  • coronary angiography
More 1st investigations to order

Investigations to consider

  • echo: stress
  • myocardial perfusion study: stress
  • coronary CT angiography
More investigations to consider

Treatment algorithm


Syed Wamique Yusuf

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center




SWY declares that he has no competing interests.

Dr Syed Wamique Yusuf would like to gratefully acknowledge Dr Iyad N. Daher, the previous contributor to this topic. IND declares that he has no competing interests.

Peer reviewersVIEW ALL

Associate Professor of Pediatrics

Medical Director

Pediatric Cardiothoracic Intensive Care Unit

University of Michigan Congenital Heart Center

Ann Arbor



JC declares that he has no competing interests.


Emergency Cardiac Service ICCU

Department of Cardiology

Rabin Medical Center

Petah Tikva



ZI declares that he has no competing interests.

Kerckhoff Heart and Thorax Center

Bad Nauheim



HM declares that he has no competing interests.

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