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Unstable angina

Last reviewed: 4 Sep 2023
Last updated: 07 Mar 2023



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


presumed cardiac chest pain


non-ST-elevation acute coronary syndrome


confirmed UA (nonelevated cardiac biomarkers)



Syed Wamique Yusuf, MBBS, FRCPI
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 reviewers

John Charpie, MD, PhD

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.

Zaza Iakobishvili, MD, PhD


Emergency Cardiac Service ICCU

Department of Cardiology

Rabin Medical Center

Petah Tikva



ZI declares that he has no competing interests.

Helge Mollmann, MD

Kerckhoff Heart and Thorax Center

Bad Nauheim



HM declares that he has no competing interests.

  • Unstable angina images
  • Differentials

    • Stable angina
    • Prinzmetal (variant or vasospastic) angina
    • Non-ST-elevation myocardial infarction
    More Differentials
  • Guidelines

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    • Guideline for coronary artery revascularization
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  • Patient leaflets

    Unstable angina: what is it?

    Unstable angina: what treatments work?

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  • Calculators

    Thrombolysis in Myocardial Infarction (TIMI) Score for Unstable Angina Non ST Elevation Myocardial Infarction

    GRACE Score for Acute Coronary Syndrome Prognosis

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