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>=== | ||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Classification''' | |||
| align="center" style="background:#f0f0f0;"|'''Symptoms''' | |||
| align="center" style="background:#f0f0f0;"|'''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 | |||
|} | |||
{{Clinical features ACS}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
===History<ref>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).</ref>=== | ===Work-Up=== | ||
*[[ECG]] +/- telemetry | |||
*[[Troponin]] if possible acute event | |||
===Diagnosis=== | |||
Rule out [[unstable angina|unstable angina]]: | |||
*New angina | |||
*Angina at rest | |||
*Accelerating frequency or severity | |||
====History<ref>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).</ref>==== | |||
*Assess: | *Assess: | ||
**Changes in angina or heart failure symptoms | **Changes in angina or heart failure symptoms | ||
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**Medication side effects | **Medication side effects | ||
===Physical Examination<ref>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).</ref>=== | ====Physical Examination<ref>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).</ref>==== | ||
*Resting heart rate and blood pressure | *Resting heart rate and blood pressure | ||
*Signs of heart failure | *Signs of heart failure | ||
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*New or worsening vascular bruits or murmurs | *New or worsening vascular bruits or murmurs | ||
*Status of abdominal aorta | *Status of abdominal aorta | ||
==Management<ref>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).,</ref>== | ==Management<ref>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).,</ref>== |
Latest revision as of 16:46, 26 September 2019
Background
- Chest pain due to cardiac ischemia
- Distinguish from unstable angina, which is defined as angina occurring at rest, for first time, or with increasing frequency/severity
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]
- Chest pain radiating to both arms > R arm > L arm
- Chest pain associated with diaphoresis
- Chest pain associated with nausea/vomiting
- Chest pain with exertion
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
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
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
- ↑ Campeau, L. Grading of angina pectoris. Circulation 1976; 54:5223
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 5.0 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.
- ↑ 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.
- ↑ 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).
- ↑ 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).
- ↑ 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).,