Last reviewed: 14 Apr 2021
Last updated: 14 Apr 2021



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


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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