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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

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Imran  TF, Malapero  R, Qavi  AH,  et al. Efficacy of spinal cord stimulation as an adjunct therapy for chronic refractory angina pectoris. Int J Cardiol. 2017;227:535–542.  [PubMed: 27836302] ...

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