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PATIENT CASE

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A 54-year-old man presents with a 3-month history of progressive chest pain. He describes a band-like retrosternal heaviness that is brought on by walking more than 2 blocks. The discomfort lasts less than 20 minutes and is relieved with rest. His past medical history is significant for hypertension. He is a nonsmoker and has no history of diabetes. His baseline Seattle Angina Questionnaire (SAQ) frequency score is 50, suggesting almost daily angina. In addition to lisinopril, his family physician has recently maximized the patient on optimally tolerated doses of metoprolol, nitroglycerin, and rosuvastatin (20 mg). At a visit with his primary care physician 12 months ago, his high-density lipoprotein cholesterol was 50 mg/dL, his total cholesterol was 170 mg/dL, and his blood pressure (while on lisinopril) was 135 mm Hg. Physical examination reveals a body mass index of 29 kg/m2, blood pressure of 145/75 mm Hg, and pulse of 58 bpm. His neck veins are not distended. There is no organomegaly and no peripheral edema, the apex is not displaced, he has normal S1 and S2 sounds, and no pathologic murmurs are identified.

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Baseline electrocardiogram shows normal sinus rhythm without ischemia, infarction, or chamber enlargement. During the exercise stress test, the patient is able to exercise for 7 minutes with 2 mm of horizontal ST-segment depression 5 minutes after initiation of exercise lasting 2 minutes into recovery. He develops nonlimiting angina during exercise. Subsequent cardiac catheterization shows a proximal left anterior descending artery lesion of borderline significance. Fractional flow reserve decreased from 0.92 at rest to 0.80 after 150 μg of intracoronary adenosine.

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DIFFERENTIAL DIAGNOSIS

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Chest pain is a highly heterogeneous clinical entity with a wide array of possible etiologies ranging from relatively benign to life-threatening conditions.1,2 The diagnostic evaluation of chest pain should be performed in parallel with management of symptoms and initiation of nonpharmacologic and pharmacologic preventive therapies.1-3 In the outpatient setting, the most common causes are musculoskeletal and gastrointestinal conditions. Chronic chest pain attributable to atherosclerotic coronary artery disease is denoted angina pectoris, which constitutes the most common manifestation of ischemic heart disease (IHD). Other causes of chest pain that have to be considered in the differential diagnosis include pulmonary causes (eg, pleuritis, pulmonary embolism, pneumonia), gastrointestinal causes (eg, biliary disease, peptic ulcer disease, esophagitis), chest wall disorders (eg, costochondritis or herpes zoster), psychiatric causes (eg, anxiety disorders, chronic pain syndrome, factitious disorders), noncoronary cardiac causes (eg, pericarditis or aortic dissection), and nonatherosclerotic coronary causes (eg, vasculitis, coronary spasm, coronary microvascular disease). Of note, a comprehensive diagnostic approach to angina pectoris should include the assessment of concomitant secondary pathologies that may trigger or exacerbate ischemic chest pain, including thyroid disorders, valvular diseases, anemia, hypoxemia, metabolic acidosis, uremia, hypertrophic cardiomyopathy, medication toxicity, and drug abuse.

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DEFINITIONS, PATHOPHYSIOLOGY, AND CLINICAL PRESENTATION OF STABLE ANGINA

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IHD ...

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