Unstable angina non ST elevation myocardial infarction symptoms

Unstable angina pectoris
Plaque rupture in a coronary artery at arrows yielding obstructive thrombus in red. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology
ICD-10	I20
ICD-9	413
DiseasesDB	8695
eMedicine	med/133
MeSH	D000787

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Synonyms and related keywords: progressive angina, crescendo angina, accelerating angina, new-onset angina, pre-infarction angina, unstable angina pectoris, UAP, UA

History and Symptoms

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.

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

• The nature of the anginal symptoms such as chest discomfort, dyspnea to establish to presence of the syndrome

Other features of the history are directed at assessing the patient's risk:

• Prior history of CAD (e.g., prior myocardial infarction (MI), angina, cardiac catheterization, coronary artery bypass grafting (CABG))
• Male gender
• Older age
• An increasing number of traditional risk factors. Other pertinent medical history which will help with risk-stratification should also be obtained rapidly, including cardiac risk factors (i.e., family history of premature coronary artery disease in a first degree relative < 60 yrs old, elevated cholesterol, hypertension, diabetes mellitus, smoking history past or present), current medications and allergies.

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 not infrequent.

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 coctail" does relieve the pain is less suggestive of ACS, although ACS 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)

• Angina pectoris at rest within 1 week of presentation
• Angina pectoris increasing to at least Canadian Cardiovascular Society Classification III or IV
• New onset of angina pectoris; (Canadian Cardiovascular Society Classification class III or IV within 2 months of presentation)
• Non-Q-wave myocardial infarction
• Post-myocardial infarction angina (>24 hours)
• Variant angina

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)

References

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