Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Angina pectoris Positive stress test for myocardial ischemia, especially exercise ECG or stress myocardial perfusion abnormalities Normal or near-normal epicardial coronary arteries Majority are women No evidence of coronary spasm on ambulatory ECG monitoring or coronary angiography +++ GENERAL CONSIDERATIONS ++ This syndrome is different from metabolic syndrome X Microvascular endothelial dysfunction is believed to be the cause, but its etiology is unclear Has been reported in 3–20% of patients undergoing coronary angiography for angina symptoms depending on the exclusion criteria employed. Most studies exclude patients with: – Valvular heart disease – Diabetes mellitus – Left ventricular hypertrophy – Systemic hypertension – Cardiomyopathy – Systolic heart failure – Left bundle branch block +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Atypical chest pain in many patients Classic effort angina in a majority Chest pain possibly severe and disabling Angina may occur with exertion or at rest but seldom at night Poor or worsening response to nitrates +++ PHYSICAL EXAM FINDINGS ++ Positive findings uncommon Evidence of autonomic dysfunction in an occasional patient +++ DIFFERENTIAL DIAGNOSIS ++ Variant angina pectoris Missed coronary artery lesions because of inadequate angiography Other causes of chest pain with a false-positive stress test, such as esophageal dysmotility Neuropsychiatric disorder +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ CBC to exclude anemia as an etiology for chest pain Metabolic panel Lipid panel Fasting glucose, hemoglobin A1c +++ ELECTROCARDIOGRAPHY ++ ECG may be abnormal Holter monitoring may show ST depression even if stress test was negative +++ IMAGING STUDIES ++ Stress echocardiogram and nuclear stress tests may be abnormal +++ DIAGNOSTIC PROCEDURES ++ Coronary angiogram to exclude epicardial lesions or vasospasm +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Patients with angina are referred to cardiologists on most occasions +++ HOSPITALIZATION CRITERIA ++ Persistent severe pain Accelerating symptoms +++ MEDICATIONS ++ Reassurance; prognosis is good Calcium channel blockers Statins even if lipids normal Vasodilatory beta blockers for selected patients Ranolazine for selected patients Omega-3 fatty acids in some patients Spinal cord stimulation in selected cases Estrogen in some cases +++ MONITORING ++ Reevaluation during exacerbation +++ DIET AND ACTIVITY ++ Cardiac low-fat diet Physical exercise or cardiac rehabilitation +++ ONGOING MANAGEMENT +++ HOSPITAL DISCHARGE CRITERIA ++ Control of symptoms After angiogram findings are known, patients may be managed as outpatients ++... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth