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Key Features

Essentials of Diagnosis

  • Precordial chest pain, usually precipitated by stress or exertion, and rapidly relieved by resting or nitrates

  • ECG, echocardiographic, or scintigraphic evidence of ischemia during pain or stress testing

  • Angiographic evidence of significant obstruction of major coronary vessels

General Considerations

  • Usually due to atherosclerotic coronary artery disease

  • Less common causes

    • Congenital anomalies

    • Emboli

    • Arteritis

    • Dissection

    • Severe myocardial hypertrophy

    • Severe aortic stenosis or regurgitation

  • Commonly exacerbated by increased metabolic demands (eg, hyperthyroidism, anemia, tachycardias)

  • Coronary vasospasm may occur at the site of a lesion or, less frequently, in apparently normal vessels spontaneously, or by exposure to cold, emotional stress, vasoconstricting medications, or cocaine

Demographics

  • Underdiagnosed in postmenopausal women

Clinical Findings

Symptoms and Signs

  • Diagnosis depends primarily on the history

  • Angina most commonly arises during activity and is relieved by rest

  • Patient often prefers to remain upright rather than lie down

  • Rather than "pain," patient may describe tightness, squeezing, burning, pressure, choking, aching, bursting, "gas," indigestion, or ill-characterized discomfort

  • Discomfort behind or slightly to the left of the mid-sternum

  • May radiate to

    • Left shoulder and upper arm

    • Medial aspect of arm, elbow, forearm, wrist, and fourth and fifth fingers

    • Right shoulder or arm

    • Lower jaw

    • Nape of neck

    • Interscapular area

  • May be associated with systemic symptoms, such as nausea, diaphoresis, dyspnea, palpitations

  • Diagnosis strongly supported if sublingual nitroglycerin aborts or attenuates length of attack

  • Physical examination during an attack often reveals a significant elevation in systolic and diastolic blood pressure

  • Hypotension is a more ominous sign

  • Gallop rhythm and an apical systolic murmur due to transient mitral regurgitation from papillary muscle dysfunction are present during pain only

  • Supraventricular or ventricular arrhythmias may be present, either as the precipitating factor or as a result of ischemia

Differential Diagnosis

  • Cardiovascular

    • Myocardial infarction (MI)

    • Pericarditis

    • Aortic stenosis

    • Aortic dissection

    • Cardiomyopathy

    • Myocarditis

    • Mitral valve prolapse

    • Pulmonary hypertension

    • Hypertrophic cardiomyopathy

    • Carditis in acute rheumatic fever

    • Aortic regurgitation

    • Right ventricular hypertrophy

  • Pulmonary

    • Pneumonia

    • Pleuritis

    • Bronchitis

    • Pneumothorax

    • Tumor

    • Mediastinitis

  • Gastrointestinal

    • Esophageal rupture

    • Gastroesophageal reflux disease

    • Esophageal spasm

    • Mallory-Weiss tear

    • Peptic ulcer disease

    • Biliary disease

    • Pancreatitis

    • Functional gastrointestinal pain

  • Musculoskeletal

    • Cervical or thoracic disk disease or arthritis

    • Shoulder arthritis

    • Costochondritis or Tietze syndrome

    • Subacromial bursitis

  • Other

    • Anxiety

    • Herpes zoster

    • Breast disorders

    • Chest wall tumors

    • Thoracic outlet syndrome

Diagnosis

Laboratory Tests

  • Troponin and creatine kinase (CK-MB) to evaluate for acute coronary syndrome

  • Obtain a fasting lipid profile

  • Rule out diabetes mellitus and anemia

Imaging Studies

  • Indications for myocardial stress imaging (scintigraphy, echocardiography, MRI)

    • Patients are physically unable to exercise

    • ECG is difficult to interpret (eg, LBBB)

    • Results of exercise testing contradict the clinical impression

    • Need to localize the ischemia more precisely

    • Assess the completeness of revascularization

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