Summary
Definition
History and exam
Key diagnostic factors
- typical angina symptoms
- atypical angina symptoms
- symptoms of low-risk unstable angina
- normal exam
Other diagnostic factors
- known medical history of exacerbating factor
- nonanginal chest pain
- epigastric discomfort
- jaw pain
- arm pain
- dyspnea on exertion
- nausea/vomiting
- perspiration (diaphoresis)
- fatigue
- hypoxia
- tachycardia
- S3
- mitral regurgitation murmur
- bibasilar rales
- aortic outflow murmur
- carotid bruit
- diminished peripheral pulses
- signs of abdominal aortic aneurysm
- retinopathy seen on fundoscopic examination
- xanthomas or xanthelasma
Risk factors
- advancing age
- smoking
- hypertension
- elevated LDL cholesterol
- isolated low HDL cholesterol
- diabetes
- inactivity
- obesity
- illicit drug use
- male sex
- family history of ischemic heart disease
- hypertriglyceridemia
- mental stress/depression
- plasma biomarkers
- polluted air
Diagnostic investigations
1st investigations to order
- resting ECG
- hemoglobin
- lipid profile
- fasting blood glucose or HbA1c
Investigations to consider
- exercise ECG (without imaging)
- exercise or pharmacologic stress with imaging
- cardiac CT angiography (CCTA)
- invasive coronary angiography
- thyroid-stimulating hormone
- CXR
- rest echocardiography
Emerging tests
- CT myocardial perfusion (CTP) and fractional flow reserve CT (FFRCT)
- coronary artery calcium (CAC) scoring
Treatment algorithm
Contributors
Authors
General Medicine Service
Veterans Affairs (VA) Puget Sound Health Care System
Assistant Professor
University of Washington
Seattle
WA
Disclosures
DB declares that he has no competing interests.
Head, Division of General Internal Medicine
Professor of Medicine and Health Services
University of Washington
Seattle
WA
Disclosures
SDF declares that he has no competing interests.
Dr Douglas Berger and Dr Stephan D. Fihn would like to gratefully acknowledge Dr Karen E. Segerson, Dr Mark C. Zaros, Dr Joy Bucher, and Dr Steven M. Bradley, previous contributors to this topic.
Disclosures
KES, MCZ, JB, and SMB declare that they have no competing interests.
Peer reviewers
Associate Professor
University of Texas MD Anderson Cancer Center
Department of Cardiology
Houston
TX
Disclosures
SWY declares that he has no competing interests.
Associate Professor of Pediatrics
Medical Director
Pediatric Cardiothoracic Intensive Care Unit
University of Michigan Congenital Heart Center
C.S. Mott Children's Hospital
Ann Arbor
MI
Disclosures
JRC declares that he has no competing interests.
Fellow
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx
NY
Disclosures
MAS declares that he has no competing interests.
Associate Professor of Medicine
Division of Cardiology
Johns Hopkins Medical Institutions
Baltimore
MD
Disclosures
KW declares that she has no competing interests.
Professor of Cardiovascular Medicine
Director of Clinical Research
Vanderbilt University
Nashville
TN
Disclosures
DL declares that he has no competing interests.
Director
Section of Transcatheter Treatment of Congenital Heart Disease in the Adult
Rovigo General Hospital
Rovigo
Italy
Disclosures
GR declares that he has no competing interests.
Use of this content is subject to our disclaimer