Unstable angina / non ST elevation myocardial infarction diagnosis

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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

Diagnosis of Unstable Angina Pectoris

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. [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]

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:

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)

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)

Laboratory Findings

Electrolyte and Biomarker Studies

If there is an elevation of a marker of myocardial necrosis (CK-MB or troponin), then the patient does not have unstable angina, but instead has a syndrome of either ST elevation MI or Non ST elevation MI depending upon the EKG changes.

Electrocardiogram

The resting electrocardiogram may show either

  • No changes
  • Non specific ST T wave changes
  • Flipped or inverted T waves
  • ST Depression as shown below. ST depression carries the poorest prognosis. Greater magnitudes of downsloping ST depression are associated with a poorer prognosis.


ST Depression in a patient with unstable angina

Chest X Ray

A chest X-ray is critical to aid in the exclusion of aortic dissection. A mediastinal mass consistent with a cancer may be present, but it is unlikely to present with a syndrome of accelerating chest pain. The chest X ray is critical in assessing for the presence of pulmonary edema or congestive heart failure which requires urgent treatment and confers a poorer prognosis.

Echocardiography

Segmental wall motion abnormalities can occur within minutes of coronary artery occlusion and can be useful in establishing that the pain is of cardiac origin and in determining the myocardial territory that is at risk.

Coronary Angiography

An early invasive strategy including coronary angiography may be required if aggressive medical therapy fails to stabilize the patient, if prior revascularization procedures have been performed, in the presence of recurrent angina, and in the presence of abnormal non-invasive test results.

References

  1. ↑ Ambrose JA, Winters SL, Stern A, et al: Angiographic morphology and the pathogenesis of unstable angina pectoris. J Am Coll Cardiol 1985 Mar; 5(3): 609-16. PMID 3973257
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  90. ↑ Tanabe Y, Itoh E, Suzuki K, et al: Limited role of coronary angioplasty and stenting in coronary spastic angina with organic stenosis. J Am Coll Cardiol 2002; 39:1120-1126. PMID 11923034
  91. ↑ Meisel SR, Mazur A, Chetboun I, et al: Usefulness of implantable cardioverter-defibrillators in refractory variant angina pectoris complicated by ventricular fibrillation in patients with angiographically normal coronary arteries. Am J Cardiol 2002; 89:1114-1116. PMID 11988204
  92. ↑ Bory M, Pierron F, Panagides D, et al: Coronary artery spasm in patients with normal or near normal coronary arteries. Long-term follow-up of 277 patients. Eur Heart J 1996; 17:1015-1021. PMID 8809518
  93. ↑ Shimokawa H, Nagasawa K, Irie T, et al: Clinical characteristics and long-term prognosis of patients with variant angina. A comparative study between western and Japanese populations. Int J Cardiol 1998; 18:331-349. PMID 3129375
  94. ↑ Tashiro H, Shimokawa H, Koyanagi S, Takeshita A: Clinical characteristics of patients with spontaneous remission of variant angina. Jpn Circ J 1993; 57:117-122. PMID 8450595
  95. ↑ Gibler WB, Cannon CP, Blomkalns AL, Char DM, Drew BJ, Hollander JE, Jaffe AS, Jesse RL, Newby LK, Ohman EM, Peterson ED, Pollack CV; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; Quality of Care and Outcomes Research Interdisciplinary Working Group; Society of Chest Pain Centers. Practical implementation of the Guidelines for Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction in the emergency department. Ann Emerg Med. 2005 Aug;46(2):185-97.

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