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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Typical exertional angina pectoris or its equivalents

  • Objective evidence of myocardial ischemia by ECG, myocardial imaging, or myocardial perfusion scanning

  • Likely occlusive coronary artery disease (CAD) because of history and objective evidence of prior myocardial infarction

  • Known CAD demonstrated by coronary angiography

GENERAL CONSIDERATIONS

  • Some patients are asymptomatic despite objective evidence of CAD

  • Coronary atherosclerosis is the most common cause

  • In older patients, vasculitides are not uncommon

  • In young patients with angina pectoris, coronary anomalies should be considered

  • Diseases of the ascending aorta can obstruct the coronary ostia

  • Coronary vasospasm without underlying atherosclerosis is a rare cause for angina in the United States

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Angina pectoris

  • Usually precipitated by exertion or emotional upset and relieved by rest

  • The discomfort usually subsides within 30 minutes

  • If pain lasts longer than 30 minutes, myocardial infarction should be suspected

  • The discomfort may typically radiate to the arms, neck, or jaw

  • The pain may have higher intensity at the radiating site than in the chest

  • Dyspnea may present as an anginal equivalent

  • Palpitations and syncope secondary to arrhythmia may occur

PHYSICAL EXAM FINDINGS

  • Often not helpful

  • S4 (not specific)

  • S3 and transient mitral regurgitation murmur may be heard but are not specific

  • A diagonal earlobe crease may be seen in younger patients with CAD

  • Tendon xanthoma and xanthelasma increase the likelihood that CAD is the cause of chest pain

DIFFERENTIAL DIAGNOSIS

  • Other causes of chest pain, such as:

    • – Esophageal reflux

    • – Costochondritis

  • False-positive evidence of ischemia, such as:

    • – Cardiomyopathy

    • – Technical shortcomings of tests

  • Cholecystitis

  • Peptic ulcer disease

  • Cervical radiculopathy

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Complete white blood cell count to exclude anemia and thrombocytosis as aggravating causes

  • Metabolic panel:

    • – To assess renal function

    • – Renal failure patients have a higher prevalence of CAD

    • – May also help to plan angiography depending on serum creatinine

  • Serum thyroid-stimulating hormone:

    • – To evaluate hypo- and hyperthyroidism; both may play a role in causing angina

  • Prothrombin time and partial thromboplastin time:

    • – To assess coagulation cascade

    • – To help plan intervention and use of antiplatelet and anticoagulation therapy

  • Further tests depend on other comorbidities

ELECTROCARDIOGRAPHY

  • 12-lead ECG

  • Exercise ECG

  • Ambulatory ECG monitoring

IMAGING STUDIES

  • Stress echocardiogram

  • Nuclear stress test

  • Coronary CT calcium score and angiography

DIAGNOSTIC PROCEDURES

  • Coronary angiogram

TREATMENT

CARDIOLOGY REFERRAL

  • When medical therapy is not controlling symptoms

  • Left ventricular dysfunction or heart failure

  • Accelerating angina (increasing frequency or severity)

HOSPITALIZATION CRITERIA
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