Stable Angina

Question:

You are an FY2 doctor in the GP clinic

75 year old male presented with chest pain for the past two weeks.
Talk to the patient and discuss further management plan with the patient.

DIFFERENTIALS

1. MI
2.PULMONORY EMBOLISM
3. ANGINA
4.PNEUMONIA
5.PERICARDITIS
6.TRAUMA AND MUSCULOSKELETEL CHEST PAIN

Dr: Hello I'm doctor ...... one of the junior doctors in the GP clinic. How can I help you
today?
Pt: doctor, I'm having this chest pain for the past two weeks and I am really worried about it.
Dr: I'm sorry to hear that. Do you have pain right now?
Pt: No doctor.
Dr: Good to hear that. Could you please tell me a little bit about the pain ?
Pt: It started like 2 weeks back. For exercise I usually walk up the hill near my home. In the
past 2 weeks when I climb up the hill I feel pain in my chest and it gets relieved when I take
rest for some time.
Dr: Can you please tell me where exactly the pain is?
Pt: [shows the central chest part]
Dr: Is it going anywhere else ? to your jaw? to your arms? Pt: No doctor [MI]
Dr: when you are having this pain, does it getting better when you lean forward?
[PERICARDITIS] – No.
Dr: Any recent flu or any other illness? [PERICARDITIS]
Dr: Do you have any fever/ cough/ SOB ? Pt: no doctor [ PNEUMONIA & PE]
Dr: Do you have any pain on your calf muscle ? Pt: No [PE]
Dr: Any recent flight travel? Pt: no [PE]
Dr: did you have a fall or any injury to your chest? Pt: No [MUSCULOSKELETEL PAIN]

PAST HISTORY
Dr: Is this the first time you are experiencing this ? Pt: yes doctor
Dr: any medical conditions ? heart disease/ high Blood pressure /diabetes/high cholesterol
Pt: nothing that I am aware of doctor

ASK MAFTOSA

[patient mentions he is completely healthy and haven't see any doctors in many years]
Dr: family h/o any medical conditions? Pt: No
Social History: Patient smoke 1 pack of cigarettes per day for the past 35 years
and drinks 2 glasses of alcohol every day for 30 - 35 years
Pt: How's your diet? Pt: my diet is fine. I follow a mixed diet. I eat both red meat and white
meat, also fruits and vegetables.
Dr: Good to hear that you are following a good diet. Pt: Thanks doctor
Dr: Do you know your BMI? Pt: No doctor
Dr: Is there anything else you want to tell me? Pt: no doctor

Dr: Mr....... I would like to examine you. Is it okay if I examine your chest, your neck and
also I wish to measure your heart rate, your blood pressure and oxygen levels in the blood?
Pt: ok doctor

[examiner gives findings: PR: 80 BP 120/80 SPO2 98%]

Dr: do you know what is happening to you ? Pt: No

Dr: Do you have any specific concerns in your mind?
Pt: Is it heart attack doctor?
Dr: Mr....... from what you have told me and after the examination, you do not have heart
attack. But I suspect that you have a condition in the heat called STABLE ANGINA. Do you
know anything about it? Pt: no doc
Dr: I will explain it. Our heart has its own blood supply for the adequate functioning of the
heart muscles. Sometimes the blood vessels called coronary arteries supplying blood to the
heart get narrowed and the blood flow to the heart muscles gets reduced which literally
means your heart muscles will not get enough oxygen to work properly. That is the reason
why you are experiencing pain on your chest.
Smoking, having high cholesterol or high BP are some factors contributing to this
narrowing of the blood vessels. Also, this condition is often triggered by physical activity or
emotional stress. Are you following me? Pt: yes doctor

Dr: Don't worry, I will talk to my seniors about you. We may need to refer you to a
Cardiologist ( heart specialist) if that's okay with you.
There are some blood test and investigations that may be required. Would you like to know
about that? Dr: yes doctor
Dr: We will do some tests to check your blood sugar and cholesterol levels. We will check
your BMI ( Body weight in relation to your height).
Specialist doctor will do some other tests like X Ray of your chest, an ECG ( heart tracing).
They may also do other tests like coronary angiography ( a scan taken after having an
injection of a dye to help highlight your heart and blood vessels),
An exercise ECG – an ECG is carried out while you are walking on a treadmill or using an
exercise bike.
A scan of heart called Echocardiography may be needed. Are you with me? Pt: yes

Treatment:
Do you want to know about the treatment options? Yes
We have few options

MEDICAL : medications are there to relieve the pain such as GTN spray. I will advise you
later how to take it. If you are found to have high cholesterol then - medications such as
STATIN may be given. We may also give other medications called Beta blockers to make
slow down heart rate, or Calcium channel blockers to increase blood supply to the heart
muscles.
Also we may give medications like Aspirin to prevent blood clots.
SURGICAL: After the assessment by the specialist doctor, if there is blockage which is
severely compromising the blood supply to the heart is detected, then specialists may do
some procedures like Angioplasty ( widening the narrowed section of the coronary artery)
or an operation called Coronary artery bypass graft (a section of the blood vessel is taken
from another part of the body and used to reroute around blocked or narrowed section of the
artery). Are you following me? Pt: yes doctor
Dr: okay Mr...... I will get in touch with my seniors right away and will do the necessary
arrangements for the referral. Is that okay?
Pt: okay doc!

LIFESTYLE : I sincerely advice you to stop smoking and cut down alcohol because they
increase the risk of having heart attack or stroke. We have lot of options available to help you
to stop this habit if you wish. What do you think ?
Pt: I'll consider that doctor
Also if your BMI is above the normal limit, modifications in the diet should also be done to
reduce your weight because being overweight is also a risk factor.
Exercise: It is good to continue doing the exercise – but build up the activity gradually and
take breaks. Keep the GTN spray with you. If the chest pain lasts more than 5 min you need
to call the ambulance.
Work – you can continue but avoid lifting heavy weights.
Sex – can continue having sex but keep GTN spray with you. You can consider using GTN
spray before the sex.
Driving – You can continue driving if you are driving light motor vehicles - Car or van. No
need to tell DVLA. [ Must tell DVLA if heavy motor driving – Lorry or Bus].

Dr: Any other concerns?

Pt: No doctor. You were so kind. Thanks!