Angina Pectoris, Chronic Stable

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 ...