Chapter 9-9: Stable Angina

TEXTBOOK PRESENTATION

Although atypical presentations are common, stable angina usually presents with symptoms of substernal chest discomfort precipitated by exertion. These symptoms resolve promptly with rest or nitroglycerin and do not change over the course of weeks. Affected patients usually have risk factors for CHD.

DISEASE HIGHLIGHTS

1. Stable angina is a chest pain syndrome caused by a mismatch between myocardial oxygen supply and demand usually caused by coronary artery stenosis.

2. Stable angina is a common first presentation for CHD.

3. Angina (stable and unstable) can also occur in the setting of normal or nearly normal coronary arteries and any of the following:

   1. Anemia

   2. Tachycardia of any cause (atrial fibrillation, hyperthyroidism)

   3. Aortic stenosis

   4. Hypertrophic cardiomyopathy

   5. Heart failure (HF) (the result of high filling pressures leading to increased coronary resistance during diastole)

It is important to consider causes of angina other than CHD.

4. Although exertional chest pain is the most common symptom of stable angina, other presentations are possible.

   1. Eliciting factors other than exercise

      1. Cold weather

      2. Extreme moods (anger, stress)

      3. Large meals

   2. Symptoms other than chest pain

      1. Dyspnea

      2. Nausea or indigestion

      3. Pain in areas other than the chest (eg, jaw, neck, teeth, back, abdomen)

      4. Palpitations

      5. Weakness and fatigue

      6. Syncope

5. The risk factors for CHD are important to elicit in any patient with concerning symptoms; the traditional risk factors are

   1. Male sex

   2. Age > 55 years in men and > 65 years in women

   3. Tobacco use

   4. Diabetes mellitus

   5. Hypertension

   6. Abnormal lipid profile

      1. Elevated low-density lipoprotein (LDL)

      2. Elevated triglycerides

      3. Elevated cholesterol/high-density lipoprotein (HDL) ratio (normal < 5:1, ideally < 3.5:1).

      4. Low HDL

   7. Other risk factors

      1. Other vascular diseases (peripheral, cerebral)

      2. Chronic kidney disease

      3. Elevated inflammatory markers (C-reactive protein among others)

      4. Lifestyle factors, such as a poor diet, sedentary lifestyle, obesity, and various psychosocial factors

      5. Cocaine use should be asked about because, although it is not a risk factor for CHD, it can cause both angina and MI.

Asking about the traditional cardiac risk factors should be a part of the history for any patient with chest pain.

6. Stable angina and CHD in women

   1. Although the pathophysiology of stable angina is the same in men and women, stable angina raises some unique issues in women that deserve comment.

   2. Stable angina presents differently in women than in men.

      1. Because angina usually presents in women at an older age than in men, there are more comorbid diseases to complicate the presentation.

      2. Women describe their chest pain differently, using terms like “burning” and “tender” more frequently.

   3. There is good evidence that the diagnostic tests used for CHD, which are discussed later in this chapter, are less accurate in women than in men.

   4. Because there is a lower prevalence of disease among women,

      1. Physicians often do not consider the diagnosis.

      2. Lower pretest probability leads to worse positive predictive value of diagnostic tests (there are more false-positive results on noninvasive tests).

EVIDENCE-BASED DIAGNOSIS

1. History

   1. The first step in diagnosing ...