Unstable Angina / Non ST Elevation Myocardial Infarction: Diagnosis

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History and Symptoms

A person with unstable angina (UA) 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. As mentioned above, UA is in the spectrum of ACS and requires immediate assessment by a qualified physician. The history and symptoms described by a patient with NSTEMI can be identical to those of the patient presenting with a STEMI and thus it is most useful to describe the classic history and symptoms suggestive of ACS.

According to the ACC/AHA UA/NSTEMI guidelines, most important factors on the initial history are

1) the nature of the anginal symptoms,

2) prior history of CAD (e.g., prior myocardial infarction (MI), angina, cardiac catheterization, coronary artery bipass grafting (CABG)),

3) male gender,

4) older age

5) an increasing number of traditional risk factors. andersonref1 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.giblerref1

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. Indeed, sometimes it is described as the sensation of "an elephant is sitting on the chest." However, in reality the history can be quite variable. The pain is sometimes 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. andersonref1 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. giblerref1 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. andersonref1

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.giblerref1

Physical Examination

Vital signs and appearance are two of the most important aspects of the physical exam. These two components of the physical exam can be assessed quickly and allow for immediate stratification into patients at higher or lower risk for death or nonfatal myocardial infarction.giblerref1

Vital Signs

In the evaluation of a patient presenting with ACS, hypotension (systolic blood pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60) indicate that a patient is at higher risk. As with the assessment of all patients, other abnormal vital signs such as hypoxia, tachypnea (RR >19), hypothermia (T <95 F) or fever (T >100.3 F) should raise concern, although they are not specifically suggestive of ACS. If aortic dissection is considered in the differential diagnosis, blood pressure should be taken in both arms (>20 mm Hg differential is suggestive of aortic dissection).

Appearance of the Patient

A patient who appears anxious, diaphoretic, with pale skin and who is in obvious respiratory distress should demand immediate attention.

Eyes

The eye exam is typically not the focus of a physical exam for ACS, however, details such as pale conjunctiva (suggestive of anemia), exopthalmos (suggestive of hyperthyroidism), or cotton-wool spots (suggestive of hypertension), or retinopathy (suggestive of diabetes) on fundoscopic exam should be noted as they may allow for the identification of potential precipitants of or risk factors for myocardial ischemia.

Ear Nose and Throat

The ears and nose are typically not the focus of a physical exam for ACS. However, the examination of the buccal mucosa can help to determine a patient's volume status, as can the examination of the right internal jugular vein pulsations (JVP). JVP measured greater than 4 cm above the sternal angle (9 cm above the right atrium) is considered elevated and reflects elevated right atrial pressure.

Heart

The cardiac exam should evaluate for signs of cardiac failure, such as a 3rd heart sound ("gallop," from early diastolic filling from left ventricular systolic failure), a 4th heart sound ("gallop," from late diastolic filling from a stiff left ventricle, as from diastolic heart failure) or a new/increased systolic murmur of mitral regurgitation (as from papillary muscle rupture). The presence of a pericardial rub would suggest pericarditis instead of ACS.

Lungs

Bibasilar rales are suggestive of congestive heart failure and pulmonary edema. However, the absence of adventitious lung sounds does not preclude diastolic heart failure.

Abdomen

The abdominal exam is typically not the focus of a physical exam for ACS. However, a finding of a expansile, pulsatile mass in the upper abdomen suggests an aortic aneurysm and requires further evaluation.

Extremities

Assess the lower extremities for edema, suggestive of heart failure. It is also important to palpate the radial, femoral and pedal pulses. Unequal radial pulses are suggestive of aortic dissection. Weak pedal pulses are suggestive of peripheral vascular disease. Femoral pulses are important to document in the event that cardiac catheterization is necessary.

Neurologic

The neurologic exam is typically not the focus of a physical exam for ACS. However, mental status at the time of the initial assessment should be documented for future reference, should the patient's mental status deteriorate during the period of observation. Also, headache in the context of chest pain and severe hypertension (i.e., SBP >210 or DBP >120) would support a diagnosis of hypertensive emergency as a cause for ACS.

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

1. No changes
2. Flipped T waves
3. ST Depression as shown to the right. ST depression carries the poorest prognosis.

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.

Differential Diagnosis of Chest Pain

Cardiovascular

• Acute Aortic Dissection
• Acute Coronary Syndrome
• Angina
• Aortic Aneurysm
• Aortic Stenosis
• Arryhthmias
• Bland-White-Garland Syndrome
• Cardiac tamponade
• Cor pulmonale
• Coronary Heart Disease
• Dressler's syndrome (postpericardiotomy)
• Functional cardiac problems
• Hypertrophic Cardiomyopathy
• Mitral valve prolapse
• Myocarditis
• Non ST Elevation Myocardial Infarction
• Pericardial tamponade
• Pericarditis
• ST Elevation Myocardial Infarction

References

1. PMID 16046952
2. PMID 17692756
3. Bickley, LS (2003). Bates' Guide to Physical Examination and History Taking. Lippincott: Philadelphia, PA. ISBN 0781735114

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Acknowledgement and Attribution Regarding Sources of Content

Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .