Ischemic heart disease is the leading cause of death among adults
in the U.S., accounting for more than 500,000 deaths annually. Atherosclerotic disease
of the epicardial coronary arteries—termed coronary
artery disease, or CAD—accounts for the vast majority
of patients with ischemic heart disease. The predominant symptom
of CAD is chest pain, and concern over potential CAD and myocardial
ischemia contributes to the >8 million visits each year to U.S.
EDs. In a typical adult ED population with acute chest pain, about
15% of patients will have an acute coronary syndrome (ACS). An consists of unstable angina and acute myocardial
infarction (AMI). Of patients with an ACS, approximately
one third have an AMI, and the remainder have unstable angina.
The Canadian Cardiovascular Society has developed
three schemes for categorizing angina. The first two categorize
angina (Table 53-0.1) and unstable angina (Table 53-0.2).1 Both assume
a diagnosis of ischemic heart disease but are not applicable to
the ED when patients present with symptoms that may or may not be
due to ischemic heart disease. The third categorization scheme assesses
the short-term risk for patients with unstable angina (Table 53-1).
Table 53-0.1 Canadian Cardiovascular Society Classification of Angina |Favorite Table|Download (.pdf)
Table 53-0.1 Canadian Cardiovascular Society Classification of Angina
|Class I||Angina occurs only with strenuous, rapid, or prolonged exertion.
Ordinary physical activity does not cause angina.|
|Class II||Slight limitation of ordinary activity. Angina occurs with climbing
stairs rapidly, walking uphill, walking after meals, in cold, in
wind, or under emotional stress.|
|Class III||Marked limitations of ordinary physical activity. Angina occurs
on walking one to two level blocks or climbing one flight of stairs
at usual pace.|
|Class IV||Inability to carry on physical activity without discomfort. Anginal
symptoms may be present at rest.|
Table 53-0.2 Principal Presentations of Unstable Angina |Favorite Table|Download (.pdf)
Table 53-0.2 Principal Presentations of Unstable Angina
|Rest angina||Angina occurring at rest and usually prolonged >20 min occurring
within 1 wk of presentation|
|New-onset angina||Angina of at least CCSC III severity with onset within 2 mo
|Increasing angina||Previously diagnosed angina that is distinctly more frequent,
longer in duration, or lower in threshold (increased by at least
one CCSC class to at least CCSC ...|
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