Last reviewed: 28 Oct 2021
Last updated: 29 Apr 2021



History and exam

Key diagnostic factors

  • chest pain
  • diaphoresis
  • recent percutaneous coronary intervention or previous coronary artery bypass graft

Other diagnostic factors

  • physical exertion
  • shortness of breath
  • weakness
  • anxiety
  • nausea
  • vomiting
  • abdominal pain
  • hypertension
  • cold exposure
  • emotional upset
  • 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 investigations

1st investigations to order

  • ECG
  • trial of sublingual nitroglycerin
  • cardiac troponins
  • CBC
  • BUN and serum creatinine
  • electrolytes
  • LFTs
  • blood glucose
  • chest x-ray

Investigations to consider

  • lipids
  • brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
  • echocardiography
  • angiography
  • stress testing
  • coronary CT angiography (CCTA)

Treatment algorithm



Cody S. Deen, MD

Assistant Professor of Medicine

Director of Cardiology

Hillsborough Hospital

University of North Carolina




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.


Dr Cody S. Deen would like to gratefully acknowledge Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic, and would also like to thank Dr Syed Wamique Yusuf for his review of the topic.


SB, MO, TV, and DK declare that they have no competing interests.

Peer reviewers

Nicolas Palaskas, MD, FACC

Assistant Professor

University of Texas MD Anderson Cancer Center




NP declares that he has no competing interests.

Edward Ullman, MD

Associate Professor

Department of Emergency Medicine

Beth Israel Medical Deaconess Center




EU declares that he has no competing interests.

Deepak L. Bhatt, MD

Associate Professor of Medicine

Department of Cardiovascular Medicine

Cleveland Clinic



DLB declares that he has no competing interests.

Shrilla Banerjee, MBMD, MRCP

Consultant Cardiologist

East Surrey Hospital

Surrey and Sussex NHS Trust




SB declares that she has no competing interests.

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