Chest Pains and Angina

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Chapter 15

Chest Pains and Angina

William Ross Brown, MD and Glenn N. Levine, MD, FACC, FAHA

1. Are most emergency room (ER) visits for chest pain caused by acute coronary syndromes (ACS)?

No. ACS (e.g., unstable angina, myocardial infarction) account for only a small percentage of ER visits for chest pain. Depending on the study, only a small percentage of patients (1% to 11%) will be diagnosed as having chest pains caused by coronary artery disease (CAD) or ACS. ACS is the term used to describe the continuum of syndromes that include unstable angina and myocardial infarction (MI).

2. What are the other important causes of chest pains besides chronic stable angina and ACS?

The differential diagnosis for chest pains include the following:

Aortic dissection

Severe aortic stenosis

Hypertrophic cardiomyopathy

Coronary artery spasm (Prinzmetal angina, cocaine abuse)

Cardiac syndrome X

Hypertensive crisis

Musculoskeletal pain and cervical radiculopathies (costochondritis)

Pulmonary embolism

Gastrointestinal (GI) causes (reflux, esophagitis, esophageal spasm, peptic ulcer disease, gallbladder disease, and esophageal rupture [Boerhaave syndrome])

Dermatologic (such as shingles)

It is important not to assume that all chest pains are due to angina or ACS, even if someone else has made such a preliminary diagnosis. This is particularly important, as time-to-diagnosis is critical for aortic dissection, where the mortality rate increases by approximately 1% every hour from presentation to diagnosis and treatment. Additionally, the treatment of aortic dissection is dramatically different from the treatment of ACS, as anticoagulation is contraindicated with aortic dissection.

3. Does an elevated troponin level make the diagnosis ACS?

Not necessarily. Although troponin elevations are fairly sensitive and specific for myocardial necrosis, it is well known that other conditions can also be associated with elevations in cardiac troponins. Importantly, troponin elevation can occur with pulmonary embolus and is in fact associated with a worse prognosis in cases of pulmonary embolus in which the troponin levels are elevated. Myopericarditis (inflammation of the myocardium and pericardium) may also cause elevated troponin levels. In addition, aortic dissection that involves the right coronary artery may lead to secondary MI. Further, troponins may be modestly chronically elevated in patients with severe chronic kidney disease. Troponin elevation has also been noted in patients with acute stroke. Studies to delineate the etiology of this are ongoing.

4. What is angina?

Angina is the term used to denote the discomfort associated with myocardial ischemia or MI. Angina occurs when myocardial oxygen demand exceeds myocardial oxygen supply, usually as a result of a severely stenotic or occluded coronary artery. Patients with angina most commonly describe a chest pain, chest pressure, or chest tightness sensation. They may also use words such as heaviness, discomfort, squeezing, or suffocating. The discomfort is more commonly over a fist or larger sized wregion than just a pinpoint (though this distinction in itself is not enough to confidently distinguish anginal from nonanginal pain). The discomfort classically occurs over the left precordium but may manifest as right-sided chest discomfort, retrosternal discomfort, or discomfort in other areas of the chest. Some persons may experience the discomfort only in the upper back, in the arm or arms, or in the neck or jaw. Angina is typically further classified into stable and unstable. Stable angina refers to angina that occurs during situations of increased myocardial oxygen demand. Unstable angina can occur at any time and falls within the spectrum of ACSs.

5. What are the associated symptoms that persons with angina may experience in addition to chest discomfort?

Patients with angina may experience one or more of the following symptoms. Some patients do not experience classic chest discomfort, but instead manifest only one or more of these associated symptoms.

Shortness of breath

Radiating pains. Patients may describe pains or discomfort that radiate to the back (typically midscapula), the neck, the jaw, or down one or both arms. They may also describe a numbness-type sensation in the arm.

6. What are the major risk factors for CAD?

Sex. Males are at higher risk of developing CAD, particularly earlier in life.

Family history of premature CAD. This is traditionally defined as a father, mother, brother, or sister who first developed clinical CAD at age younger than 45 to 55 years for men and at age younger than 55 to 60 years for women.

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