Unstable angina

Last reviewed: 4 Sep 2022
Last updated: 13 Sep 2022
22 Mar 2022

US guidelines on the diagnosis and evaluation of chest pain

In their 2021 guideline, the American College of Cardiology (ACC) and American Heart Association (AHA) outline how to classify chest pain symptoms and describe approaches to risk stratification for patients with possible acute coronary syndromes; key recommendations include:

  • Symptoms: pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, can all be considered potential anginal equivalents.

  • Terminology: "noncardiac" should be used in place of "atypical" if heart disease is not suspected.

  • Clinical decision pathways: should be used routinely when assessing patients with chest pain; integration of validated risk scores (Thrombolysis in Myocardial Infarction [TIMI] risk score and the Global Registry of Acute Coronary Events [GRACE] risk model) and/or high-sensitivity cardiac troponin testing is recommended.

See Diagnosis: approach

See Management: approach

See Management: treatment algorithm

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • increasing frequency of chest pain
  • increasing severity of chest pain
  • retrosternal chest pain radiating to jaw, arm, or neck
  • dyspnea
  • fourth heart sound (S4)
More key diagnostic factors

Other diagnostic factors

  • atypical chest discomfort
  • diaphoresis
  • nausea
  • tachycardia
  • carotid bruit
  • diminished or absent peripheral pulses
  • syncope
  • third heart sound (S3)
  • murmur
  • rales
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

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

Investigations to consider

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

Treatment algorithm

INITIAL

presumed cardiac chest pain

ACUTE

non-ST-elevation acute coronary syndrome

ONGOING

confirmed UA (nonelevated cardiac biomarkers)

Contributors

Authors

Syed Wamique Yusuf, MBBS, FRCPI
Syed Wamique Yusuf

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

TX

Disclosures

SWY declares that he has no competing interests.

Acknowledgements

Dr Syed Wamique Yusuf would like to gratefully acknowledge Dr Iyad N. Daher, the previous contributor to this topic.

Disclosures

IND declares that he has no competing interests.

Peer reviewers

John Charpie, MD, PhD

Associate Professor of Pediatrics

Medical Director

Pediatric Cardiothoracic Intensive Care Unit

University of Michigan Congenital Heart Center

Ann Arbor

MI

Disclosures

JC declares that he has no competing interests.

Zaza Iakobishvili, MD, PhD

Director

Emergency Cardiac Service ICCU

Department of Cardiology

Rabin Medical Center

Petah Tikva

Israel

Disclosures

ZI declares that he has no competing interests.

Helge Mollmann, MD

Kerckhoff Heart and Thorax Center

Bad Nauheim

Germany

Disclosures

HM declares that he has no competing interests.

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