Stable angina

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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).,