Summary
Definition
History and exam
Key diagnostic factors
- chest pain
- diaphoresis
Other diagnostic factors
- shortness of breath
- weakness
- anxiety
- nausea and vomiting
- abdominal pain
- hypertension
- early morning onset
- syncope
- hypotension
- arrhythmias
- abnormal heart sounds
Risk factors
- atherosclerosis (history of angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease)
- diabetes
- smoking
- dyslipidemia
- family history of premature coronary artery disease (CAD)
- age >65 years
- hypertension
- obesity and metabolic syndrome phenotype
- physical inactivity
- cocaine use
- depression
- stent thrombosis or restenosis
- chronic kidney disease
- surgical procedures (including intraoperative and postoperative periods)
- sleep apnea
Diagnostic tests
1st tests to order
- ECG
- cardiac biomarkers
- echocardiography
- CBC
- BUN and serum creatinine
- electrolytes
- LFTs
- blood glucose
- chest x-ray
Tests to consider
- lipids
- brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
- angiography/cardiac catheterization
- stress testing
- coronary CT angiography (CCTA)
Treatment algorithm
acute presentation
post-stabilization
Contributors
Authors
Mahi L. Ashwath, MD, MBA, FACC, FASE, FSCMR
Director, Cardiac MRI
Clinical Professor of Medicine and Radiology
Division of Cardiology
Department of Internal Medicine
University of Iowa Hospitals and Clinics
University of Iowa Health Care
Iowa
IA
Disclosures
MLA declares that she is a member of the Board of Governors of the American College of Cardiology.
Sanjay Gandhi, MD, MBA, FACC, FAHA, FSCAI
Director, Endovascular Cardiology
Professor of Medicine, Endovascular Cardiology
Case Western Reserve University
Cleveland
OH
Disclosures
SG declares that he is Senior Director of Medical Strategy and Innovation for the US market at Philips. SG is a senior advisor at Emeritus. SG is a voluntary board member of the American College of Cardiology (ACC) National Cardiovascular Data Registry oversight committee, the Chest Pain Myocardial Infarction registry steering committee, and the ACC finance committee.
Acknowledgements
Dr Mahi L. Ashwath and Dr Sanjay Gandhi would like to gratefully acknowledge Dr Cody Deen, Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic.
Disclosures
CSD was previously the Director of Cardiac Rehab for Chatham Hospital, which was financially set up as a consultancy relationship, until 2017. CSD has spoken (unpaid) at the Update in Cardiology and Update in Internal Medicine Conferences at UNC for the last 5 years. CSD has served as the PI for the Dal-GeneE (site now closed) and the ACCELERATE Trials at the University of North Carolina (trial now completed). Each trial required paid travel to an investigator meeting. SB, MO, TV, and DK declare that they have no competing interests.
Peer reviewers
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.
References
Key articles
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-228.Full text Abstract
Thygesen K, Alpert JS, Jaffe AS, et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018 Oct 30;72(18):2231-64.Full text Abstract
Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42(14):1289-367.Full text Abstract
Writing Committee Members; Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee On Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-285.Full text Abstract
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee On Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e18-114.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- ST-elevation myocardial infarction (STEMI)
- Unstable angina
- Aortic dissection
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