Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Persistent angina pectoris despite maximally tolerated doses of nitrates, beta blockers, and calcium channel blockers Diffuse coronary atherosclerosis not amenable to revascularization Relatively normal left ventricular function, which excludes heart transplantation +++ GENERAL CONSIDERATIONS ++ This situation is uncommon Diffuse disease of the coronary arteries is the usual problem +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Angina on exertion or at rest Shortness of breath +++ PHYSICAL EXAM FINDINGS ++ S4 +++ DIFFERENTIAL DIAGNOSIS ++ Precipitating or aggravating conditions such as hypertension, anemia, thyrotoxicosis Less than maximal medical therapy Second opinion on lack of feasibility of revascularization Patients with noncardiac advanced disease that prohibits revascularization +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ CBC, metabolic panel Thyroid-stimulating hormone Lipid panel High-sensitive C-reactive protein (hS-CRP) Urine toxicology screen in selected patients +++ ELECTROCARDIOGRAPHY ++ 12-lead ECG (may show ST-segment depression) +++ IMAGING STUDIES ++ Echocardiogram to evaluate left ventricular function +++ DIAGNOSTIC PROCEDURES ++ Coronary angiogram to define coronary anatomy +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Refractory symptoms or need for hospitalization +++ HOSPITALIZATION CRITERIA ++ Chest pain active and persistent Chest pain at rest or on minimal exertion +++ MEDICATIONS ++ Antianginal medications titrated to maximal tolerated doses, including ranolazine Statin group of medications to reduce low-density lipoproteins < 100 and hS-CRP below 1.0 Narcotic analgesics if necessary +++ THERAPEUTIC PROCEDURES ++ Enhanced external counterpulsation (EECP) Spinal cord stimulation +++ SURGERY ++ No proven options +++ MONITORING ++ ECG monitoring in hospital +++ DIET AND ACTIVITY ++ Cardiac low-fat diet Exercise as tolerated +++ ONGOING MANAGEMENT +++ HOSPITAL DISCHARGE CRITERIA ++ When symptoms are stable +++ FOLLOW-UP ++ Depending on symptoms, follow-up every 4–12 weeks +++ COMPLICATIONS ++ Myocardial infarction Frequent hospitalization secondary to unstable angina or non–ST-segment elevation myocardial infarction +++ PROGNOSIS ++ Prognosis is generally guarded +++ PREVENTION ++ Similar to atherosclerosis Low-fat diet Regular exercise Statins +++ RESOURCES +++ PRACTICE GUIDELINES ++ EECP is the most available, least invasive option with some benefit at least short term +++ REFERENCES... 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? 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.