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Angina, unstable

How do doctors diagnose unstable angina?

It can be hard to tell if chest pain is unstable angina. But this condition is a medical emergency. So if you have symptoms that might mean unstable angina, you, or someone with you, should dial 911 right away.

When you reach the emergency room of your hospital, the doctor will ask you some questions about the pain and discomfort in your chest and your health. He or she will also examine you and do some tests.

It isn't always easy to diagnose unstable angina. That's because there are so many other causes of chest pain. Here are some things your doctor might do to help tell if you have angina.

Questions your doctor may ask

Your doctor may ask you these questions.

How would you describe the discomfort or pain you feel?
What brings on this feeling?
How long does it last and what makes it go away?
Is there a regular pattern to it, and can you tell when it will happen?
How long have you had it, and is it getting any worse?
Do you smoke?
Does

heart disease
You get heart disease when your heart isn't able to pump blood as well as it should. This can happen for a variety of reasons.

heart disease run in your family?
Do you have

high blood pressure
Your blood pressure is considered to be high when it is above the accepted normal range. The usual limit for normal blood pressure is 140/90. If either the first (systolic) number is above 140 or the lower (diastolic) number is above 90, a person is considered to have high blood pressure. Doctors sometimes call high blood pressure "hypertension."

high blood pressure?
Do you have

high cholesterol
If you've been told that you have high cholesterol it usually means that your total cholesterol level is 240mg/dL or higher. But doctors also look at the amount of good (HDL) and bad (LDL) cholesterol you have in your blood. Having high levels of bad cholesterol can make it more likely that you'll get certain diseases in your heart and arteries.

high cholesterol?
Do you have

diabetes
Diabetes is a condition that causes too much sugar to circulate in your blood. It happens when your body stops making a hormone called insulin (type 1 diabetes) or when insulin stops working (type 2 diabetes).

diabetes?
What kind of work do you do?
What kinds of foods do you eat?

If there is any doubt about what is causing your discomfort or pain, your doctor will ask you more questions. For more, see Other causes of chest pain.

Physical examination

Your doctor will give you a physical examination to learn more about what could be causing your symptoms. Here are some things he or she may do.

Measure your

blood pressure
Blood pressure is the amount of force exerted by the blood on the walls of the vessels that carry it. You can think of it like the water pressure in your home: the more pressure you have, the faster and more forcefully the water flows out of the shower. Blood pressure is measured in millimeters of mercury (written as mm Hg). When your blood pressure is taken, the measurement is given as two numbers, for example 120/80 mm Hg. The first, higher, number is called the systolic pressure, and the second, lower, number is the diastolic pressure. The systolic number is the highest pressure that occurs while the heart is pushing blood into the arteries. The diastolic number is the lowest pressure that happens when the heart is relaxing and is not pushing the blood.

blood pressure and feel your pulse. Your pulse tells your doctor how fast your heart is beating and if the beat is regular.
Listen to your heart, especially for any extra noises called murmurs. These may be a sign of a problem with your heart valves. Sometimes valve problems can cause angina.
Listen to the blood flowing though the

arteries
Arteries are the blood vessels that take blood that is rich in oxygen and food away from your heart. The arteries carry this blood to all the tissues in your body.

arteries in your neck to see if there are any extra noises. These noises may mean that your arteries are narrowed.
Look for bumps under your skin that are a sign of high cholesterol. For example, you may have firm white bumps around your eyes. High cholesterol can put you at risk for narrowing of your arteries.
Listen to your lungs for any extra noises while you breathe. These could be caused by lung disease or by

heart failure
When the heart loses its ability to push enough blood through the circulation, it is called heart failure.

heart failure. You can get heart failure if your heart is damaged, so it doesn't pump well.
Measure your height and weight to figure out if you are overweight. If you are overweight, this puts an extra strain on your heart.
Check for less common causes of angina. For example, your doctor will look for signs of

anemia
Anemia is when you have too few red blood cells. Anemia can make you get tired and breathless easily. It can also make you look pale. Anemia can be caused by a number of different things, including problems with your diet, blood loss and some diseases.

anemia and an overactive

thyroid gland
Your thyroid gland is a small organ that sits in your neck, just in front of your windpipe. It sends out a hormone called thyroxine. This acts on receptors within cells. By acting on the receptors it gives the cells a message to speed up their metabolism and work harder.

thyroid gland. Both can cause angina. For more, see Other causes of angina.
Check for causes of chest pain that don't have anything to do with your heart. For more, see Other causes of chest pain.

If you do have angina, your doctor will also try to find out what type you have. We have looked at treatments for the type called unstable angina. But there are two other types. For more, see Other types of angina.

Tests

The most common tests for unstable angina are listed below.

Source:
Grech ED, Ramsdale DR.
Acute coronary syndrome: unstable angina and infarction non-ST segment elevation myocardial.
BMJ. 2003; 326; 1259-1261.

Source:
European Society of Cardiology.
Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.
European Heart Journal. 2002; 23, 1809-1840.

² You are likely to have an electrocardiogram (ECG for short) and a troponin test soon after you reach the hospital. You may also have some of the other tests as well, either then or later on. It depends on what your doctor thinks is wrong with you.

An electrocardiogram (ECG). The first test your doctor will suggest is an electrocardiogram, or ECG for short.

Source:
Grech ED, Ramsdale DR.
Acute coronary syndrome: unstable angina and infarction non-ST segment elevation myocardial.
BMJ. 2003; 326; 1259-1261.

¹

Source:
European Society of Cardiology.
Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.
European Heart Journal. 2002; 23, 1809-1840.

² The ECG shows the electrical activity in your heart as a line on a graph. This test helps your doctor tell if your heart is beating properly and if you have certain heart problems. See Electrocardiogram to learn more.
Blood tests. Your doctor will also suggest some blood tests. These include a test for a

proteins
A lot of your body's tissues are made out of proteins. Proteins can be made in your cells. Proteins are also part of the food you eat, particularly meat and dairy products. Your body breaks down the protein you eat into amino acids. Your cells then use these amino acids to build new proteins, which make up muscles, joints, hair and other parts of your body.

protein called troponin. This will help your doctor decide whether you have unstable angina or have had a

heart attack
Doctors call a heart attack an acute myocardial infarction (or acute MI). This is the name for the damage that occurs to the heart muscle if it isn't getting enough blood and oxygen because a branch of the coronoary arteries is blocked. During a heart attack, you may have pain or heaviness over your chest, and pain, numbness or tingling in your jaw and left arm.

heart attack. See Troponin test to learn more. Other tests can help tell if you have

anemia
Anemia is when you have too few red blood cells. Anemia can make you get tired and breathless easily. It can also make you look pale. Anemia can be caused by a number of different things, including problems with your diet, blood loss and some diseases.

anemia,

diabetes
Diabetes is a condition that causes too much sugar to circulate in your blood. It happens when your body stops making a hormone called insulin (type 1 diabetes) or when insulin stops working (type 2 diabetes).

diabetes or

high cholesterol
If you've been told that you have high cholesterol it usually means that your total cholesterol level is 240mg/dL or higher. But doctors also look at the amount of good (HDL) and bad (LDL) cholesterol you have in your blood. Having high levels of bad cholesterol can make it more likely that you'll get certain diseases in your heart and arteries.

high cholesterol. If your doctor thinks you might have an overactive

thyroid gland
Your thyroid gland is a small organ that sits in your neck, just in front of your windpipe. It sends out a hormone called thyroxine. This acts on receptors within cells. By acting on the receptors it gives the cells a message to speed up their metabolism and work harder.

thyroid gland, you'll need a blood test for that, too.
An echocardiogram. This test uses sound waves to make a picture of your heart. It's sometimes called an "echo" for short. The picture shows how blood flows through your heart and if your heart is pumping properly, among other things. See Echocardiogram to learn more.
Coronary angiography. This test uses a dye to make your

coronary arteries
Coronary arteries are the vessels that supply blood to the heart muscle. If yours are blocked, you may have a pain in your chest (known as angina) or a heart attack because parts of the heart are not getting enough blood and oxygen.

coronary arteries show up on an

X-ray
X-rays are pictures taken of the inside of your body. They are done by passing very small amounts of radiation through your body and onto film. X-rays can also be used as a treatment, such as in radiation therapy for cancer.

X-ray. It can show blockages. See Coronary angiography to learn more.
A trial of treatment. Your doctor may give you a treatment for angina to see if it takes away your discomfort or pain. The treatment is called nitroglycerin.
An X-ray. If your doctor thinks you might have lung disease or

heart failure
When the heart loses its ability to push enough blood through the circulation, it is called heart failure.

heart failure rather than unstable angina, you will need an X-ray of your chest.
A stress test. When your symptoms have settled down and your doctor is sure that you are not in danger, he or she may advise you to have a stress test, or to come back to the hospital to have it at another time. Stress tests make your heart work harder. They can uncover problems that don't show up while you're resting. See Stress test to learn more.

Figuring out your risk

Some people with unstable angina are at greater risk than others of having a heart attack or other serious heart problems. By figuring out your risk, your doctor can decide which treatment is best for you. For more, see Unstable angina: figuring out your risk.

Sources for the information on this page:

Grech ED, Ramsdale DR.Acute coronary syndrome: unstable angina and infarction non-ST segment elevation myocardial.BMJ. 2003; 326; 1259-1261.

European Society of Cardiology.Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.European Heart Journal. 2002; 23, 1809-1840.

This information was last updated on May 11, 2009

This information is for educational use only, and is not a substitute for prompt professional medical advice. Readers should always consult a physician or other professional for advice and treatment.
© BMJ Publishing Group Limited 2009. All rights reserved.

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