Angina Pectoris in Emergency Medicine Workup

  • Author: Marc D Haber, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Nov 23, 2010
 

Laboratory Studies

  • CBC (anemia, leukocytosis may suggest an alternative diagnosis)
  • BUN and creatinine level, if intravenous contrast is anticipated
  • Electrolyte levels are of virtually no value unless the patient is on a diuretic and concern for an abnormality exists.
  • Cardiac enzyme levels, if positive may suggest non–ST-segment elevation myocardial infarction (NSTEMI); negative results do not rule out ischemia
  • Coagulation studies, if anticoagulation or antiplatelets are anticipated
  • Type and screen, if surgery or transfusions are considered
Next

Imaging Studies

Chest radiography is used to rule out an alternative diagnosis or contributing factors (eg, pneumothorax [PTX], pneumonia [PNA], congestive heart failure); it is also used to evaluate the aorta prior to anticoagulant administration.

CT of the chest may be considered for evaluation of aortic or pulmonary disease; if evaluating the aorta, include the abdominal aorta. Of note, the forthcoming "triple rule out CT scan" exposes the patient to an exorbitantly high dose of radiation and should only be used in certain circumstances.

Limited CT coronary scans may help to reduce the posttest probability of coronary artery disease while utilizing potentially less radiation exposure than the "triple rule out scan." Coronary artery calcification suggests the presence of an atherosclerotic plaque. Calcium scores are determined by the density of calcium and the total area. Higher calcium scores may suggest a higher risk of current or future adverse cardiac events. Multiple sites are currently conducting trials to see if this modality will benefit patients in the emergency department.

Bamberg et al found that, in patients with acute chest pain and an inconclusive initial evaluation (nondiagnostic electrocardiographic findings, negative cardiac biomarkers), age and gender can serve as simple criteria to select patients who would derive the greatest diagnostic benefit from coronary computed tomographic angiography (CTA).[13] In an observational cohort study in 368 low-risk patients, positive findings on 64-slice coronary CTA led to restratification to high risk, and negative findings led to restratification to very low risk, in men younger than 55 years and women younger than 65 years. In contrast, in women older than 65 years and men older than 55 years, a negative result on CTA did not result in restratification to a low-risk category.

Nuclear imaging should include V/Q (PE evaluation) and resting Sestamibi (In the appropriate clinical setting, a normal study in a patient with ongoing chest pain may rule out myocardial ischemia.[14] ).

ECG results may be normal or show signs of ischemia. Main use is to establish a baseline and R/O acute ST-segment elevation myocardial infarction (STEMI).

Intraluminal coronary artery sonography (ICAS) is a highly invasive modality that may provide additional information to a patient's coronary artery anatomy and disease. Coronary atherosclerosis, which does not result in coronary artery narrowing, may be missed by conventional forms of coronary angiography. If clincially suspected, ICAS may be utilized to detect the presence or absence of such lesions. ICAS is not readily available; as such, it is highly unlikely that ICAS will be utilized from the emergency department in the foreseeable future.

The use of stress cardiac MRI in an observation unit may be a cost-saving alternative to inpatient management for emergency department patients with chest pain. In a randomized study in 110 patients, Miller et al reported that an observation unit strategy with stress cardiac MRI reduced median hospitalization cost by approximately $588, with no cases of missed acute coronary syndrome.[15]

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Marc D Haber, MD  Assistant Professor, Department of Emergency Medicine, Baystate Medical Center, Tufts University School of Medicine; President of Young Physician Section, AAEM

Marc D Haber, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas A Brunell, MD, MA, FACEP, FAAEM  Director, Emergency Medicine Education, St Francis Hospital and Medical Center; Assistant Professor of Traumatology and Emergency Medicine, University of Connecticut Medical Center

Thomas A Brunell, MD, MA, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeffrey L Arnold, MD, FACEP  Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Clarendon E. The Life of Edward, Earl of Clarendon. Oxford at the Clarendon Press; 1827:18.

  2. Jay V. The legacy of William Heberden. Arch Pathol Lab Med. Dec 2000;124(12):1750-1. [Medline].

  3. Kelemen MD. Angina pectoris: evaluation in the office. Med Clin North Am. May 2006;90(3):391-416. [Medline].

  4. Maseri A, Crea F, Kaski JC, Davies G. Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis. Jul-Aug 1992;35(1):1-18. [Medline].

  5. Servoss SJ, Januzzi JL, Muller JE. Triggers of acute coronary syndromes. Prog Cardiovasc Dis. Mar-Apr 2002;44(5):369-80. [Medline].

  6. Yang EH, Lerman A. Management of the patient with chest pain and a normal coronary angiogram. Cardiol Clin. Nov 2005;23(4):559-68, viii. [Medline].

  7. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. Jan 27 2009;119(3):e21-181. [Medline]. [Full Text].

  8. Centers for Disease Control and Prevention. Prevalence of heart disease--United States, 2005. MMWR Morb Mortal Wkly Rep. Feb 16 2007;56(6):113-8. [Medline]. [Full Text].

  9. Almeda FQ, Kason TT, Nathan S, Kavinsky CJ. Silent myocardial ischemia: concepts and controversies. Am J Med. Jan 15 2004;116(2):112-8. [Medline].

  10. Clarke WB, Austin SM, Shah PM, Griffin PM, Dove JT, McCullough J, et al. Spectral energy of the first heart sound in acute myocardial ischemia. A correlation with electrocardiographic, hemodynamic, and wall motion abnormalities. Circulation. Mar 1978;57(3):593-8. [Medline].

  11. Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. Mar 2002;9(3):203-8. [Medline].

  12. Tierney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med. Jul 1985;13(7):526-31. [Medline].

  13. Bamberg F, Truong QA, Blankstein R, Nasir K, Lee H, Rogers IS, et al. Usefulness of age and gender in the early triage of patients with acute chest pain having cardiac computed tomographic angiography. Am J Cardiol. Nov 1 2009;104(9):1165-70. [Medline].

  14. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. Dec 4 2002;288(21):2693-700. [Medline].

  15. [Best Evidence] Miller CD, Hwang W, Hoekstra JW, Case D, Lefebvre C, Blumstein H, et al. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med. Sep 2010;56(3):209-219.e2. [Medline].

  16. Chen EH, Mills AM. Is it necessary to admit low-risk patients with suspected acute coronary syndrome to inpatient telemetry beds?. Ann Emerg Med. Nov 2005;46(5):440-4. [Medline].

  17. Kou V, Nassisi D. Unstable angina and non-ST-segment myocardial infarction: an evidence-based approach to management. Mt Sinai J Med. Jan 2006;73(1):449-68. [Medline].

  18. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation. Apr 1994;89(4):1545-56. [Medline].

  19. Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet. Sep 4-10 2004;364(9437):849-57. [Medline].

  20. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. Nov 15 1989;64(18):1087-92. [Medline].

  21. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. Jul 1996;14(4):341-5. [Medline].

  22. Rogers JT. Risk Management in Emergency Medicine. 1985:4-6.

  23. American Heart Association, American Stroke Association. Heart Disease and Stroke Statistics --2006 Update. Available at http://circ.ahajournals.org/content/113/6/e85.extract.

  24. [Guideline] Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. Aug 4 2004;44(3):671-719. [Medline].

  25. [Guideline] Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. Oct 2 2002;40(7):1366-74. [Medline]. [Full Text].

  26. Kaski JC, Rosano GM, Collins P, Nihoyannopoulos P, Maseri A, Poole-Wilson PA. Cardiac syndrome X: clinical characteristics and left ventricular function. Long-term follow-up study. J Am Coll Cardiol. Mar 15 1995;25(4):807-14. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.