Ischemic Heart Disease, Chronic

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 ...