Unstable Angina Differential Diagnoses

http://emedicine.medscape.com/article/159383-differential

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Unstable Angina Differential Diagnoses

Author: Walter A Tan, MD, MS; Chief Editor: Eric H Yang, MD more... Updated: Dec 7, 2011

Diagnostic Considerations
Patients in whom the diagnosis of myocardial infarction or unstable angina has been missed and those who are sent home from the emergency department have, respectively, a 2- and 1.7-fold increased risk of death compared with those who were admitted to the hospital. This a public health issue, and up to 20% of the millions of dollars awarded in malpractice suits against emergency department practitioners is for missed acute coronary syndrome. As shown in one study, unintentional failure to recognize or hospitalize patients with myocardial infarction or unstable angina occurred in an average of 2.2 per 100 patients presenting to the emergency department with a chest pain syndrome, with rates of 0-10% across different academic centers. Even more disturbing, the presence of a well-established chest pain unit was not related to lower rates of missed diagnosis. Although eliminating missed diagnoses of acute ischemic syndromes is impossible without undue hospitalization rates and costs, this problem could be minimized by the following means: Addressing factors or preconceptions that obscure correct diagnosis in women and nonwhite patients, subgroups that are at higher risk for missed diagnosis Recognition of angina equivalents, particularly in elderly patients More careful history taking to account for recent changes in the character or course of anginal symptoms Use of confirmatory point-of-care cardiac enzyme assays that have a high negative predictive value in patients with nonspecific or normal electrocardiographic findings Predischarge stress testing in stable patients at low risk who have a moderate likelihood of coronary artery disease Awareness that absence of ECG or early cardiac enzyme elevation does not automatically preclude the possibility of acute ischemia, because these are merely snapshots in time of a dynamic process Observation and serial or further testing should be considered for patients who have coronary risk factors or a suspicious history. Be aware that unstable angina or acute myocardial infarction can infrequently coexist or concurrently present with the following: Aortic dissection with involvement of the right coronary artery ostium Infective endocarditis with embolus into a coronary artery Periprocedural (post-PCI) reocclusion or coronary stent thrombosis Congestive heart failure in association with positive cardiac enzymes Consider cocaine-induced coronary spasm, which can be indistinguishable from acute coronary syndromes. (Nitroglycerin and calcium-channel antagonists are the drugs of choice. Beta-blockers may exacerbate cocaine-

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Unstable Angina Differential Diagnoses

http://emedicine.medscape.com/article/159383-differential

induced coronary vasoconstriction.) In patients with persistent ST elevation, coronary angiography should be performed. If this cannot be carried out immediately, consider empiric fibrinolytic therapy. Variant (Prinzmetal) angina is characterized by transient ST-segment elevation and can involve multiple coronary arterial territories. Patients typically respond to nitroglycerin and high-dose, and sometimes even dual, calciumchannelblocker therapy. The differential diagnoses for unstable angina fall into the following categories: Cardiac Vascular Pulmonary Gastrointestinal Musculoskeletal Other

Differential Diagnoses
Anxiety Disorders Aortic dissection Aortic Stenosis Arthritis of the shoulder or spine Biliary Disease Cervical disc disease Costochondritis Disorders of the breast Esophageal Reflux Esophageal Spasm Herpes zoster Hypertrophic obstructive cardiomyopathy Intercostal muscle cramps Interscalene or hyperabduction syndromes Mallory-Weiss Tear Mediastinitis Microvascular disease (syndrome X) Pancreatitis, Acute Pancreatitis, Chronic Peptic Ulcer Disease Pericarditis, Acute Pericarditis, Constrictive Pericarditis, Constrictive-Effusive Pneumonia, Aspiration Pneumonia, Bacterial Pneumonia, Fungal Pneumonia, Viral Pneumothorax Pulmonary Embolism Pulmonary hypertension Pulmonary Hypertension, Primary Pulmonary Hypertension, Secondary Right ventricular strain due to severe pulmonary hypertension Subacromial bursitis Tracheobronchitis Tumor Tumors of the chest wall

Contributor Information and Disclosures

Author Walter A Tan, MD, MS Associate Professor of Medicine, Clinical Associate Professor of Surgery, Director of Stroke Interventions, Associate Director of Cardiac Catheterization, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University

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Unstable Angina Differential Diagnoses

http://emedicine.medscape.com/article/159383-differential

Walter A Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American Heart Association, American Stroke Association, National Stroke Association, Society for Vascular Medicine and Biology, and Society of Interventional Radiology Disclosure: Gilead Honoraria Other Coauthor(s) David J Moliterno, MD Professor of Medicine, Jefferson Morris Gill Professor of Cardiology, Chief, Division of Cardiovascular Medicine, University of Kentucky; Vice Chairman of Internal Medicine, Chandler Medical Center; Medical Director, Gill Heart Institute David J Moliterno, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Association of Professors of Cardiology, and European Society of Cardiology Disclosure: Nothing to disclose. George A Stouffer III, MD Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions Disclosure: Nothing to disclose. Josh W Todd, MD Fellow in Interventional Cardiology, University of North Carolina at Chapel Hill Josh W Todd, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, and American Heart Association Disclosure: Nothing to disclose. Specialty Editor Board Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Director of Cardiology Quality Program KMC, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, Cardiac Society of Australia and New Zealand, and German Cardiac Society Disclosure: Nothing to disclose. Chief Editor Eric H Yang, MD Associate Professor of Medicine, Director of Interventional Cardiology Fellowship Program, Henry Ford Hospital

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Unstable Angina Differential Diagnoses

http://emedicine.medscape.com/article/159383-differential

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha Disclosure: Nothing to disclose. Additional Contributors The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Steven James Filby, MD, Robert Vincent Kelly, MD, Jeb Burchenal, MD, James Maddux, MD, and Jorge Davalos, MD, to the development and writing of the source articles.

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