Diagnostic Considerations

As previously stated, there is no standard presentation of angina. One must be vigilant for anginal equivalents, such as breathlessness or diaphoresis, in all subgroups of patients.

No amount of testing can routinely be performed in the emergency department setting to definitively rule out angina as the cause of a patient's chest pain or suspected anginal equivalent.

Reproducible chest wall pain is found in roughly 10% of all cases of AMI.^[13]

Missed MIs account for approximately 10% of malpractice claims against emergency physicians and 24% of payout.^{[14, 15]}

Other conditions to be considered in the differential diagnosis of patients with suspected angina include the following:

Hypertrophic cardiomyopathy
Gastric ulcers
Hypertension
Pneumonia with pleural involvement
Pulmonary hypertension, primary
Pulmonary hypertension, secondary
Tietze syndrome
Varicella-zoster virus anemia

Differential Diagnoses

Workup

Clarendon E. The Life of Edward, Earl of Clarendon. Oxford at the Clarendon Press; 1827. 18.
Jay V. The legacy of William Heberden. Arch Pathol Lab Med. 2000 Dec. 124(12):1750-1. [QxMD MEDLINE Link].
Kelemen MD. Angina pectoris: evaluation in the office. Med Clin North Am. 2006 May. 90(3):391-416. [QxMD MEDLINE Link].
Maseri A, Crea F, Kaski JC, Davies G. Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis. 1992 Jul-Aug. 35(1):1-18. [QxMD MEDLINE Link].
Servoss SJ, Januzzi JL, Muller JE. Triggers of acute coronary syndromes. Prog Cardiovasc Dis. 2002 Mar-Apr. 44(5):369-80. [QxMD MEDLINE Link].
Yang EH, Lerman A. Management of the patient with chest pain and a normal coronary angiogram. Cardiol Clin. 2005 Nov. 23(4):559-68, viii. [QxMD MEDLINE Link].
Mozaffarian D, Benjamin EJ, Go AS, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2015 update: a report from the american heart association. Circulation. 2015 Jan 27. 131(4):e29-e322. [QxMD MEDLINE Link].
Virani SS, Alonso A, Benjamin EJ, et al, for the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020 Mar 3. 141(9):e139-e596. [QxMD MEDLINE Link]. [Full Text].
Almeda FQ, Kason TT, Nathan S, Kavinsky CJ. Silent myocardial ischemia: concepts and controversies. Am J Med. 2004 Jan 15. 116(2):112-8. [QxMD MEDLINE Link].
Clarke WB, Austin SM, Shah PM, et al. Spectral energy of the first heart sound in acute myocardial ischemia. A correlation with electrocardiographic, hemodynamic, and wall motion abnormalities. Circulation. 1978 Mar. 57(3):593-8. [QxMD MEDLINE Link]. [Full Text].
Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. 2002 Mar. 9(3):203-8. [QxMD MEDLINE Link].
Tierney WM, Roth BJ, Psaty B, et al. Predictors of myocardial infarction in emergency room patients. Crit Care Med. 1985 Jul. 13(7):526-31. [QxMD MEDLINE Link].
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. 1989 Nov 15. 64(18):1087-92. [QxMD MEDLINE Link].
Karcz A, Korn R, Burke MC, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996 Jul. 14(4):341-5. [QxMD MEDLINE Link].
Rogers JT. Risk Management in Emergency Medicine. 1985. 4-6.
Bamberg F, Truong QA, Blankstein R, 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. 2009 Nov 1. 104(9):1165-70. [QxMD MEDLINE Link]. [Full Text].
Udelson JE, Beshansky JR, Ballin DS, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002 Dec 4. 288(21):2693-700. [QxMD MEDLINE Link]. [Full Text].
Miller CD, Hwang W, Hoekstra JW, 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. 2010 Sep. 56(3):209-219.e2. [QxMD MEDLINE Link]. [Full Text].
Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26. 367(4):299-308. [QxMD MEDLINE Link].
Chen EH, Mills AM. Is it necessary to admit low-risk patients with suspected acute coronary syndrome to inpatient telemetry beds?. Ann Emerg Med. 2005 Nov. 46(5):440-4. [QxMD MEDLINE Link].
Kou V, Nassisi D. Unstable angina and non-ST-segment myocardial infarction: an evidence-based approach to management. Mt Sinai J Med. 2006 Jan. 73(1):449-68. [QxMD MEDLINE Link].
[Guideline] Collet JP, Thiele H, Barbato E, et al, for the ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020 Aug 29. 49(5):1198-1205. [QxMD MEDLINE Link]. [Full Text].
Zoler ML. ESC’s revised NSTE-ACS guidelines embrace hsT, personalized anti-ischemia treatments. Medscape Medical News. September 1, 2020. Available at https://www.medscape.com/viewarticle/936676. Accessed: : January 13, 2021.
[Guideline] Amsterdam EA, Wenger NK, Brindis RG, et al, for the ACC/AHA Task Force Members. 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. Circulation. 2014 Dec 23. 130(25):e344-426. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016 Jan 14. 37(3):267-315. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable isc... Circulation. 2016 Sep 6. 134(10):e123-55. [QxMD MEDLINE Link]. [Full Text].
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. 1994 Apr. 89(4):1545-56. [QxMD MEDLINE Link].
Poole-Wilson PA, Lubsen J, Kirwan BA, et al, for the Coronary disease Trial Investigating Outcome with Nifedipine gastrointestinal therapeutic system investigators. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet. 2004 Sep 4-10. 364(9437):849-57. [QxMD MEDLINE Link].
Lloyd-Jones D, Adams R, Carnethon M, et al, for the for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009 Jan 27. 119(3):e21-181. [QxMD MEDLINE Link]. [Full Text].
Centers for Disease Control and Prevention. Prevalence of heart disease--United States, 2005. MMWR Morb Mortal Wkly Rep. 2007 Feb 16. 56(6):113-8. [QxMD MEDLINE Link]. [Full Text].
Thom T, Haase N, Rosamond W, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006 Feb 14. 113 (6):e85-151. [QxMD MEDLINE Link]. [Full Text].
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. 1995 Mar 15. 25(4):807-14. [QxMD MEDLINE Link].
[Guideline] Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Rev Esp Cardiol (Engl Ed). 2016 Dec. 69(12):1167. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

of 0

Table 5. Recommendations for Selection of Preferred Management Strategy

Table 5. Recommendations for Selection of Preferred Management Strategy

Preferred Strategy	Patient Characteristic/Clinical Risk
Immediate Invasive Strategy (< 2 hours)	Refractory angina
	Signs/symptoms of heart failure or new or worsening mitral regurgitation
	Hemodynamic instability or cardiogenic shock
	Recurrent angina/ischemia at rest or with low-level activities despite intensive medical therapy
	Sustained ventricular tachycardia or ventricular fibrillation
Ischemia-Guided Strategy	Low-risk score (eg, TIMI 0 or 1, GRACE < 109)
	Low-risk Tn-negative female
	Patient or physician preference in the absence of high-risk features
Early Invasive Strategy (< 24 hours)	GRACE score >140
	Rise or fall in Tn compatible with myocardial infarction
	New or presumably new ST-segment depression
Delayed Invasive Strategy (24-72 hours)	Diabetes mellitus
	Renal insufficiency (GFR < 60 mL/min/1.73m²)
	Reduced LV systolic function (LVEF < 40%)
	Early postinfarction angina
	PCI within 6 months
	Prior CABG
	GRACE score 109-140; TIMI Score ≥2
ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass grafting; GFR = glomerular filtration rate; 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; Tn = troponin.