From the Guidelines
A workup for chest pain with exertion should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG) and cardiac biomarkers like troponin, as recommended by the European Society of Cardiology in 2013 1. The initial assessment should focus on distinguishing between cardiac and non-cardiac causes, with particular attention to risk factors for coronary artery disease.
- A careful history remains the cornerstone of the diagnosis of chest pain, allowing for the classification of discomfort into typical angina, atypical angina, and noncardiac chest pain 1.
- The characteristics of discomfort related to myocardial ischemia (angina pectoris) include location, character, duration, and relationship to exertion and other exacerbating or relieving factors, such as pressure, tightness, or heaviness in the chest, jaw, shoulder, back, or arm 1. Additional testing typically includes stress testing, which may be exercise ECG, stress echocardiography, or nuclear perfusion imaging depending on the patient's baseline ECG and exercise capacity.
- For patients with intermediate to high pre-test probability of coronary artery disease, coronary CT angiography or invasive coronary angiography may be warranted 1. Basic laboratory tests should include complete blood count, comprehensive metabolic panel, lipid profile, and hemoglobin A1c.
- During the evaluation, it's appropriate to initiate medical therapy with aspirin 81-325mg daily, sublingual nitroglycerin 0.4mg as needed for acute chest pain, and consideration of a statin and beta-blocker depending on risk factors, as suggested by the American College of Physicians in 2004 1. Patients should be counseled to seek immediate medical attention if they experience prolonged chest pain (>20 minutes), pain at rest, or pain associated with dyspnea, nausea, or diaphoresis.
- This systematic approach helps identify potentially life-threatening conditions like acute coronary syndrome while also evaluating for other causes of exertional chest pain such as aortic stenosis, hypertrophic cardiomyopathy, or pulmonary disorders 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Initial Evaluation
The workup for angina (chest pain with exertion) typically involves the following steps:
- History taking to determine whether the chest pain is cardiac in origin or not 2
- Physical examination to identify any signs or symptoms that may indicate acute coronary syndrome (ACS) 3
- Electrocardiogram (ECG) to check for any abnormalities that may suggest ACS 3, 2
- Cardiac biomarkers, such as troponin, to diagnose acute myocardial infarction 4, 3
Risk Stratification
Risk stratification scores, such as the HEART and TIMI scores, can be used to identify patients who are at high or low risk of ACS 3, 5
- The HEART score incorporates the patient's history, ECG, age, risk factors, and troponin level to predict the likelihood of ACS 3
- The TIMI score also takes into account the patient's history, ECG, and troponin level, as well as other risk factors 3, 5
- These scores can help clinicians determine which patients require further testing or admission to the hospital 3, 5
Further Testing
If the initial workup is equivocal, further testing may be necessary to evaluate the patient's risk of ACS 5
- Coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (FFR) are non-invasive imaging modalities that can be used to evaluate patients with suspected ACS 5
- These tests can help identify patients who have significant coronary artery disease (CAD) and require further intervention 5
Management
The management of ACS involves a range of treatments, including medication, angiography, and revascularization procedures 6