Unstable angina
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.
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)
Other diagnostic factors
- atypical chest discomfort
- diaphoresis
- nausea
- tachycardia
- carotid bruit
- diminished or absent 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 coronary artery disease (CAD)
- hypertension
- smoking
- diabetes mellitus
- hyperlipidemia
- peripheral vascular disease
- chronic kidney disease
- elevated CRP levels
- mediastinal radiation
- obesity/lack of exercise
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
Investigations to consider
- echocardiogram: stress
- myocardial perfusion study: stress
- coronary CT angiography
Treatment algorithm
presumed cardiac chest pain
non-ST-elevation acute coronary syndrome
confirmed UA (nonelevated cardiac biomarkers)
Contributors
Authors
Syed Wamique Yusuf, MBBS, FRCPI
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.
Differentials
- Stable angina
- Prinzmetal (variant or vasospastic) angina
- Non-ST-elevation myocardial infarction
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- Guideline for coronary artery revascularization
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