Stable angina: Difference between revisions
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==Background==
==Background==
*[[Chest pain]] due to [[myocardial ischemia|cardiac ischemia]]
*Distinguish from [[unstable angina]], which is defined as angina occurring at rest, for first time, or with increasing frequency/severity


==Clinical Features==
==Clinical Features==
===Classes (Canadian Cardiovascular Society Classification)<ref>Campeau, L. Grading of angina pectoris. Circulation 1976; 54:5223</ref>===
===Classes (Canadian Cardiovascular Society Classification)<ref>Campeau, L. Grading of angina pectoris. Circulation 1976; 54:5223</ref>===
*Grade I
{| {{table}}
**Symptoms with prolonged exertion
| align="center" style="background:#f0f0f0;"|'''Classification'''
**No limitation of ordinary activities
| align="center" style="background:#f0f0f0;"|'''Symptoms'''
*Grade II
| align="center" style="background:#f0f0f0;"|'''Limitation of Ordinary Activities'''
**Symptoms walking >2 blocks or climbing >1 flight of stairs
|-
**Slight limitation of ordinary activities
| Grade I||With prolonged exertion||None
*Grade III
|-
**Symptoms walking <2 blocks
| Grade II||Walking >2 blocks or climbing >1 flight of stairs||Slight
**Marked limitation of ordinary activities
|-
*Grade IV
| Grade III||Walking <2 blocks||Marked
**Symptoms with minimal activity or at rest
|-
**Cannot do any ordinary physical activity without symptoms
| Grade IV||With minimal activity or at rest||Cannot do any without symptoms
|}
 
{{Clinical features ACS}}


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Work-Up===
===Work-Up===
*ECG +/- telemetry
*[[ECG]] +/- telemetry
*Troponin if possible acute event
*[[Troponin]] if possible acute event


===Diagnosis===
===Diagnosis===

Latest revision as of 16:46, 26 September 2019

Background

Clinical Features

Classes (Canadian Cardiovascular Society Classification)[1]

Classification Symptoms Limitation of Ordinary Activities
Grade I With prolonged exertion None
Grade II Walking >2 blocks or climbing >1 flight of stairs Slight
Grade III Walking <2 blocks Marked
Grade IV With minimal activity or at rest Cannot do any without symptoms

Risk of ACS

Clinical factors that increase likelihood of ACS/AMI:[2][3]

Clinical factors that decrease likelihood of ACS/AMI:[4]

  • Pleuritic chest pain
  • Positional chest pain
  • Sharp, stabbing chest pain
  • Chest pain reproducible with palpation

Gender differences in ACS

  • Women with ACS:
    • Less likely to be treated with guideline-directed medical therapies[5]
    • Less likely to undergo cardiac catheterization[5]
    • Less likely to receive timely reperfusion therapy[5]
    • More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[5] although some studies have found fewer differences in presentation[6]
  • More likely to delay presentation[5]
  • Men with ACS:
    • More likely to report central chest pain

Factors associated with delayed presentation[5]

  • Female sex
  • Older age
  • Black or Hispanic race
  • Low educational achievement
  • Low socioeconomic status

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Evaluation

Work-Up

Diagnosis

Rule out unstable angina:

  • New angina
  • Angina at rest
  • Accelerating frequency or severity

History[7]

  • Assess:
    • Changes in angina or heart failure symptoms
    • Adherence to prescribed medications
    • Changes in medications
    • Medication side effects

Physical Examination[8]

  • Resting heart rate and blood pressure
  • Signs of heart failure
  • New dysrhythmia
  • New or worsening vascular bruits or murmurs
  • Status of abdominal aorta

Management[9]

  • Counsel regarding appropriate use of medications, nutrition, weight optimization, smoking cessation

Disposition

  • If angina is stable and there is no other reason for admission, may discharge home for further management by family physician or cardiologist

See Also

External Links

References

  1. ↑ Campeau, L. Grading of angina pectoris. Circulation 1976; 54:5223
  2. ↑ Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
  3. ↑ Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
  4. ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
  6. ↑ Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.
  7. ↑ Mancini, G et al. (2014) Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease. Canadian Journal of Cardiology, 30(8).
  8. ↑ Mancini, G et al. (2014) Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease. Canadian Journal of Cardiology, 30(8).
  9. ↑ Mancini, G et al. Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease (2014). Canadian Journal of Cardiology, 30(8).,
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