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

• Is a manifestation of stable coronary artery disease (CAD) or chronic coronary syndromes

• Usually due to atherosclerotic CAD

• 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

• Patients with coronary disease should undergo aggressive risk factor modification, with a focus on

  • Statin treatment

  • Treatment of hypertension (defined by American Heart Association at the 130 mm Hg level)

  • Cigarette smoking cessation

  • Exercise and weight control (especially for patients with metabolic syndrome or at risk for diabetes)

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 in most cases

• 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

• Duration of symptoms

  • Generally of short duration and subsides completely

  • If the attack is precipitated by exertion and the patient stops to rest, angina usually lasts < 3 minutes

  • Attacks following a heavy meal or brought on by anger often last 15–20 minutes

  • Attacks > 30 minutes are unusual; suggest acute coronary syndrome (ACS) with unstable angina, myocardial infarction, or an alternative diagnosis

• 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

  • Pericarditis

  • Aortic stenosis, aortic regurgitation

  • Aortic dissection

  • Cardiomyopathy, myocarditis

  • Mitral valve prolapse

  • Pulmonary hypertension

  • Hypertrophic cardiomyopathy

  • Carditis ...