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 Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process 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 Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.