Unstable Angina Clinical Presentation
- Author: Walter Tan, MD, MS; Chief Editor: Eric H Yang, MD more...
Patients with unstable angina represent a heterogeneous population. Therefore, the clinician must obtain a focused history of the patient’s symptoms and coronary risk factors and immediately review the electrocardiogram (ECG) to develop an early risk stratification. (See Prognosis.)
Initially, obtain a history to determine whether any evidence of angina is present, then aim to identify whether it is stable or unstable.
Unstable angina differs from stable angina in that the discomfort is usually more intense and easily provoked, and ST-segment depression or elevation on ECG may occur. Otherwise, the manifestations of unstable angina are similar to those of other conditions of myocardial ischemia, such as chronic stable angina and myocardial infarction (MI).
Angina can take many forms, and inquiry should be directed at eliciting not only chest pain but also any associated discomfort and its frequency, location, radiation pattern, and precipitating and alleviating factors.
Ischemic pain can manifest as heaviness, tightness, aching, fullness, or burning of the chest, epigastrium, or arm or forearm (usually the left). These sensations less typically involve the lower jaw, neck, or shoulder. Important associated symptoms may be dyspnea, generalized fatigue, diaphoresis, nausea and vomiting, flulike symptoms, and, less commonly, lightheadedness or abdominal pain. The intensity of pain on a 1-10 scale does not correlate with diagnosis or prognosis.
Elderly and female patients are more likely to present with atypical signs and symptoms.
The physical examination is usually not as sensitive or specific for unstable angina as the history or diagnostic tests. An unremarkable physical examination is not uncommon. Perform a quick assessment of patients’ vital signs, and perform a cardiac examination. Specific diagnoses that must be explicitly considered are the following:
Leaking or ruptured thoracic aneurysm
Pericarditis with tamponade
Peptic ulcer disease
Increased autonomic activity may manifest as diaphoresis or tachycardia, and bradycardia may result from vagal stimulation from inferior wall myocardial ischemia.
A large area of myocardial jeopardy may manifest as signs of transient myocardial dysfunction and typically signifies a higher-risk situation. Such signs include the following:
Systolic blood pressure less than 100 mm Hg or overt hypotension
Elevated jugular venous pressure
Reverse splitting of the second heart sound
Presence of a third or fourth heart sound
New or worsening apical systolic murmur due to papillary muscle dysfunction
Rales or crackles
Findings indicative of peripheral arterial occlusive disease or prior stroke increase the likelihood of associated coronary artery disease (CAD) and are as follows:
Supraclavicular or femoral bruits
Diminished peripheral pulses or blood pressure
Any sign of congestive heart failure (CHF), including isolated sinus tachycardia, particularly in physiologically vulnerable populations (eg, very elderly patients), should trigger expeditious workup, treatment, or consultation with a cardiologist. Such patients can deteriorate rapidly.
The number and diversity of clinical conditions that cause the transient myocardial ischemia of unstable angina, along with its varying intensity and frequency of pain, have made classification within this disorder difficult.
The Braunwald classification (see Table 4 below) is conceptually useful, in that it factors in the clinical presentation (new or progressive vs rest angina), context (primary, secondary, or post-MI), and intensity of antianginal therapy.
Table 4. Braunwald Classification of Unstable Angina (Open Table in a new window)
|Severity||I||Symptoms with exertion|
|II||Subacute symptoms at rest (2-30 days prior)|
|III||Acute symptoms at rest (within prior 48 hr)|
|Clinical precipitating factor||A||Secondary|
|Therapy during symptoms||1||No treatment|
|2||Usual angina therapy|
Patients in Braunwald class I have new or accelerated exertional angina, whereas those in class II have subacute (>48 hours since last pain) or class III acute (< 48 hours since last pain) rest angina. The clinical circumstances associated with unstable angina are categorized as follows:
Secondary (anemia, fever, hypoxia)
Postinfarction (< 2 weeks after MI)
Intensity of antianginal therapy is subclassified as follows:
Usual oral therapy
Intense therapy (eg, intravenous [IV] nitroglycerin)
Canadian Cardiovascular Society Grading System
Because of its simplicity and practicality, the Canadian Cardiovascular Society Grading System for effort-related angina is widely used to describe symptom severity. The grading system is as follows:
Grade I – Angina with strenuous, rapid, or prolonged exertion; ordinary physical activity, such as climbing stairs, does not provoke angina
Grade II – Slight limitation of ordinary activity; angina occurs with postprandial, uphill, or rapid walking; when walking more than 2 blocks of level ground or climbing more than 1 flight of stairs; during emotional stress; or in the early hours after awakening
Grade III – Marked limitation of ordinary activity; angina occurs with walking 1-2 blocks or climbing a flight of stairs at a normal pace
Grade IV – Inability to carry on any physical activity without discomfort; rest pain occurs
Acute Coronary Syndrome Risk Assessment
Estimation of the likelihood of acute coronary syndrome (ACS) is a complex, multivariable problem that cannot be fully specified in the list below, which is meant more to illustrate major relations than to offer rigid algorithms. A high likelihood of ACS includes any of the following features:
History of previous MI, sudden death, or other known history of CAD
Chest, neck, jaw, or left arm pain consistent with prior documented angina
Transient hemodynamic or ECG changes during pain
ST-segment elevation or depression of 1 mm or more
Marked symmetrical T-wave inversion in multiple precordial leads
An intermediate likelihood of ACS includes the absence of high-likelihood features but the presence of 1 of the following risk characteristics:
Age greater than 70 years
Extracardiac vascular disease (peripheral, brachiocephalic, or renal artery atherosclerosis)
ST depression of 0.05-1 mm
T-wave inversion of 1 mm or greater in leads with dominant R waves
A low likelihood of ACS includes the absence of high- or intermediate-likelihood features and the presence of any of the following:
Chest pain classified as probably not angina
Chest discomfort reproduced by palpation
T-wave flattening or inversion of less than 1 mm in leads with dominant R waves
Normal ECG findings
Thrombolysis in Myocardial Infarction Risk Score
The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for unstable angina/non-ST elevation MI (UA/NSTEMI) is currently the best-validated prognostic instrument that is simple enough to use in settings such as an emergency department. The gradient of MI, severe recurrent ischemia, or death is somewhat proportionate to the TIMI Risk Score (see the image below), though an adverse prognosis appears to be mitigated by the use of newer antithrombotic strategies.
The presence of any of the following variables constitutes 1 point, with the sum constituting the patient risk score on a scale of 0-7:
Age 65 years or older
Use of aspirin in the preceding 7 days
Known coronary stenosis of 50% or greater
Elevated serum cardiac markers
At least 3 risk factors for CAD (including diabetes mellitus, active smoking, family history of CAD, hypertension, or hypercholesterolemia)
Severe anginal symptoms (≥2 anginal events in the preceding 24 hours)
ST deviation on ECG
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- Table 1. Patient Characteristics, GUARANTEE Versus CRUSADE Trials
- Table 2. Demographic Characteristics of Patients in International OASIS-2 Registry
- Table 3. Thirty-Day Clinical Outcome in Patients With Acute Coronary Syndromes in Clinical Trials
- Table 4. Braunwald Classification of Unstable Angina
- Table 5. ACC/AHA Recommendations for Preferred Invasive Strategy
|Characteristics||GUARANTEE, 1995-96 ||CRUSADE, 2001-06 |
|Mean age (y)||62||69|
|Patients >65 y (%)||44||–|
|Diabetes mellitus (%)||26||33|
|Current smoker (%)||25||–|
|Previous stroke (%)||9||–|
|Previous MI (%)||36||30|
|Previous angina (%)||66||–|
|Previous coronary intervention (%)||23||21|
|Previous coronary bypass surgery (%)||25||19|
|CHF = congestive heart failure; CRUSADE = Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines; GUARANTEE = Global Unstable Angina Registry and Treatment Evaluation; MI = myocardial infarction.|
|Characteristics ||Australia||Brazil||Canada||Hungary||Poland||United States|
|General||Number of patients||1899||1478||1626||931||1135||918|
|Mean age (y)||65||62||66||65||63||66|
|Clinical||NQMI presentation (%)||7||7||14||22||17||16|
|Abnormal ECG (%)||74||91||82||95||97||87|
|Select treatments||Beta blocker (%)||67||53||73||67||59||57|
|Calcium blocker (%)||59||51||53||52||43||59|
|Invasive procedures (index hospitalization)||Cardiac catheterization (%)||24||69||43||20||7||58|
|CABG = coronary artery bypass grafting; ECG = electrocardiographic; NQMI = non-Q wave myocardial infarction; OASIS = Organization to Assess Strategies for Ischemic Syndromes; PCI = percutaneous coronary intervention.|
|Study||Year||Number of Patients||Death (%)||Myocardial Infarction (%)||Major Bleed (%)|
|ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; GUSTO-IIb = Global Utilization of Streptokinase and TPA (tissue plasminogen activator) for Occluded Coronary Arteries; PARAGON-A = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PARAGON-B = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PRISM = Platelet Receptor Inhibition in Ischemic Syndrome Management; PRISM-PLUS = Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Angina Signs and Symptoms; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI-11B = Thrombolysis in Myocardial Infarction Clinical Trial 11B; TIMI-3 = Thrombolysis in Myocardial Infarction Clinical Trial 3.|
|Severity||I||Symptoms with exertion|
|II||Subacute symptoms at rest (2-30 days prior)|
|III||Acute symptoms at rest (within prior 48 hr)|
|Clinical precipitating factor||A||Secondary|
|Therapy during symptoms||1||No treatment|
|2||Usual angina therapy|
|Preferred Strategy ||Patient Characteristics|
|Invasive||Recurrent angina/ischemia at rest or with low-level activities despite intensive medical therapy|
|Elevated cardiac biomarkers (TnT or TnI)|
|New or presumably new ST-segment depression|
|Signs or symptoms of heart failure or new or worsening mitral regurgitation|
|High-risk findings on noninvasive stress testing|
|High-risk score (eg, TIMI, GRACE)|
|Reduced LV systolic function (LVEF < 40%)|
|Sustained ventricular tachycardia|
|PCI within 6 months|
|Conservative||Low-risk score (eg, TIMI, GRACE)|
|Patient or physician preference in the absence of high-risk features|
|ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass grafting; GRACE = Global Registry of Acute Coronary Events; LV = left ventricle; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis in Myocardial Infarction Clinical Trial; TnI = troponin I; TnT = troponin T.|