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.
Unstable angina most commonly presents with chest pain and/or dyspnea, although atypical symptoms may be present.
Initial risk stratification and management depends on the clinical features, ECG, and biomarkers (troponin).
ECG typically shows ST segment depression and T-wave inversion, but may be normal.
Acute management includes antiplatelet and antithrombotic therapy to reduce the extent of myocardial damage and complications.
Long-term management includes reduction of risk factors and use of medication to prevent recurrence.
Unstable angina (UA) is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage. It is characterized by specific clinical findings of prolonged (>20 minutes) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of myocardial infarction.
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
- fourth heart sound (S4)
Other diagnostic factors
- atypical chest discomfort
- carotid bruit
- diminished or absent peripheral pulses
- third heart sound (S3)
- female sex
- personal history of coronary artery disease (CAD)
- increased age
- family history of coronary artery disease (CAD)
- diabetes mellitus
- peripheral vascular disease
- chronic kidney disease
- elevated CRP levels
- mediastinal radiation
- obesity/lack of exercise
1st investigations to order
- cardiac biomarkers
- electrolytes and renal function
- blood sugar
- lipid profile
- coagulation profile
- echocardiogram: rest
- myocardial perfusion study: rest
- CT chest or MRI
- coronary angiography
Investigations to consider
- echocardiogram: stress
- myocardial perfusion study: stress
- coronary CT angiography
presumed cardiac chest pain
non-ST-elevation acute coronary syndrome
confirmed UA (nonelevated cardiac biomarkers)
Syed Wamique Yusuf, MBBS, FRCPI
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.
John Charpie, MD, PhD
Associate Professor of Pediatrics
Pediatric Cardiothoracic Intensive Care Unit
University of Michigan Congenital Heart Center
JC declares that he has no competing interests.
Zaza Iakobishvili, MD, PhD
Emergency Cardiac Service ICCU
Department of Cardiology
Rabin Medical Center
ZI declares that he has no competing interests.
Helge Mollmann, MD
Kerckhoff Heart and Thorax Center
HM declares that he has no competing interests.
- Stable angina
- Prinzmetal (variant or vasospastic) angina
- Non-ST-elevation myocardial infarction
- Guideline for the evaluation and diagnosis of chest pain
- Guideline for coronary artery revascularization
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