Unstable angina non ST elevation myocardial infarction symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

A person with unstable angina pectoris (UAP) will have a history of angina that has increased in frequency or intensity at the same level of exertion. Anginal pain can manifest in many forms ranging from chest pain to chest pressure to shortness of breath to epigastric pain. UAP is part of the spectrum of acute coronary syndromes (ACS) and requires immediate assessment and management by a qualified physician. The history and symptoms described by a patient with unstable angina can be identical to the symptoms of either NSTEMI or STEMI, both of which carry a poorer prognosis.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]
[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94]

History

According to the ACC/AHA, UA/NSTEMI guidelines, the most important features of the initial history are:

Symptoms

Typical Symptoms

The most common history given by a patient with ACS is that of chest discomfort, described as crushing, left-sided substernal chest pain or pressure that radiates to the neck or left arm. Patients will sometimes deny the presence of chest pain, and instead will indicate that only a discomfort or heaviness is present. For this reason, the term chest discomfort is preferred over the term chest pain. Sometimes the discomfort is described as a heaviness or the sensation of "an elephant is sitting on the chest". While there are classic descriptions of the chest discomfort that occurs in the setting of unstable angina, the location and nature of the pain can be quite variable. The discomfort can sometimes be located solely in the epigastric region, the right side of the chest, the jaw, neck, arm, shoulder or back and a history of nausea, dyspnea or diaphoresis is common.

Atypical Symptoms

It is important to note that certain patient populations may be even less likely to present with classic symptoms. These groups include women, older patients and patients with renal failure and diabetes. Pleuritic pain (sharp pain on inspiration or from a cough), mid/lower abdominal pain, pain reproducible with palpation or movement, very brief episodes of pain (e.g., seconds) and pain that radiates to the lower extremities are all traits that are less likely to be from -although they do not exclude - ACS.

Similarly, a history that nitroglycerine does not relieve the pain or a history that a 'GI cocktail' does relieve the pain is less suggestive of ACS, althoughACS still cannot be excluded on this basis.

A thorough history of present illness (HPI) obtained by the physician will include the time of onset, duration, location, radiation, quality, intensity, aggravating and relieving factors (i.e., deep breathing, position, exertion), associated symptoms (i.e., diaphoresis, nausea, vomiting, dyspnea, dizziness), any history of prior similar symptoms along with a comparison of the pain to any previously diagnosed angina.

Features of Chest Pain or Chest Discomfort, Which are Not Characteristic of Myocardial Ischemia

  • Pain which radiates into the lower extremities.
  • Pleuritic pain (sharp or knife like pain brought on by respiratory movements or cough).
  • Primary or sole location of discomfort in the middle or lower abdominal region.
  • Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costochondral junction.
  • Pain reproduced with movement or palpation of the chest wall or arms.
  • Very brief episodes of pain that last a few seconds or less.

Possible Clinical Presentation of Unstable Angina Pectoris (In Alphabetical Order)

The most frequent clinical presentations are as follow:

  • Angina at rest: Angina occurring at rest and prolonged, usually greater than 20 min.
  • New onset of angina pectoris: New onset angina of at least CCS class III severity
  • Increasing angina severity: Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by 1 or more CCS class to at least CCS class III severity)

2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (DO NOT EDIT)[96]

Clinical Assessment (DO NOT EDIT)[97]

Class I
"1. Patients with symptoms that may represent ACS should not be evaluated solely over the telephone but should be referred to a facility that allows evaluation by a physician and the recording of a 12-lead ECG and biomarker determination (e.g., an ED or other acute care facility).(Level of Evidence: C)"
"2. Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s], back, neck, jaw orepigastrium; shortness of breath; weakness; diaphoresis; nausea; lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B)"
"3. Health care providers should actively address the following issues regarding ACS with patients with or at risk for CHD and their families or other responsible caregivers:
a. The patients heart attack risk; (Level of Evidence: C)
b. How to recognize symptoms of ACS; (Level of Evidence: C)
c. The advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 min, despite feelings of uncertainty about the symptoms and fear of potential embarrassment; (Level of Evidence: C)
d. A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access EMS, generally 9-1-1.[98] (Level of Evidence: C)"
"4. Prehospital EMS providers should administer 162 to 325 mg of ASA (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: C)"
"5. Health care providers should instruct patients with suspected ACS for whom nitroglycerin [[[NTG]]] has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/ pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (Level of Evidence: C)"
"6. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED. Other patients with suspected ACS who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (Level of Evidence: C)"
Class IIa
"1. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients without a history of ASA allergy who have symptoms of ACS to chew ASA (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used entericcoated ASA for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. (Level of Evidence: B)"
"2. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients who tolerate NTG to repeatNTG every 5 min for a maximum of 3 doses while awaiting ambulance arrival. (Level of Evidence: C)"
"3. It is reasonable that all prehospital EMS providers perform and evaluate 12-lead ECGs in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions. Electrocardiographs with validated computer-generated interpretation algorithms are recommended for this purpose. (Level of Evidence: B)"
"4. If the 12-lead ECG shows evidence of acute injury or ischemia, it is reasonable that prehospital ACLS providers relay the ECG to a predetermined medical control facility and/or receiving hospital. (Level of Evidence: B)"

References

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