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Angina Self Study

Department of Internal
A 56 year old male presents for
evaluation of heaviness in chest
while mowing his lawn. There is
no cough, but some dyspnea.
Symptoms abate after a cold
drink and a few minutes break.
He feels worn out afterwards
for several hours.
He has no history of chronic
illness, and these symptoms
are recent. He takes no
medication. He smokes an
occasional cigarette. He has
not had a physical for at least
10 years
On examination, his BP is
148/96 with a pulse of 90. He
has a soft bruit over the right
carotid. Cardiac ascultation
reveals an S4 at the apex.
Lungs are clear. Abdomen is
benign, as is his peripheral
Recognizing Clinical Clues to the
Diagnosis of Angina
Clues in the History
ClassicLevine sign correlates well
in males
Pressure or squeezing sensation
more correlative than pain
Radiation pattern to left arm,
shoulder, jaw, neck or hand
Associated diaphoresis and nausea
are ominous markers
Clues in the History
Significantischemia often results in
prolonged periods of fatigue
Ischemic pain rarely lasts longer than
thirty minutes
Ischemia presents as painless
dyspnea in 25% of cases
Clues in the History
Pain with activity, or pain with
activity and at rest correlates with
ischemia better than pain only at rest
Pattern of discomfort in women
highly variable
Claudication separate from chest
Risk Stratification by History
Major risks
Diabetes mellitus
Family History of premature
atherosclerosis in first degree relative
Lipid disorder (high LDL, or low HDL)
Clues in the Physical
Evidence of vascular disease
funduscopic exam- copper wiring or plaque
large artery bruits
pulse abnormalities

Systolic aortic murmur

Signs of cardiomegaly
displaced PMI
anterior heave
Clues in the Physical
arcus senilis
enlarged abdominal aorta
Basic Testing
any unexplained ST segment depression
Q waves indicative of prior injury
normal ECG does not rule out ischemia
Basic Testing
Troponin or CPK only indicated if high
suspicion of active ischemia, requiring
ER evaluation
CPK of diagnostic value, especially in
Basic Testing
Laboratory testing of questionable
serum homocysteine
sedimentation rate
lipid subfractions (Lpa, etc.)
antiviral or antibacterial antibodies
heavy metal screen
Provides little diagnostic information when
screening for ischemic heart disease in
absence of other evidence
Useful to confirm segmental dysfunction in
presence of abnormal ECG
Useful to define segmental abnormality in
presence of history and signs of LV
dysfunctionEcho tells us what the EF is,
based on this info, I can tell if there is poor
systolic dysfunction or not!!!
ECG Stress Testing
Excellent screen in males with normal
Accuracy in females 50% due largely to
false positivesmust do nuclear stress
test on females!!!
Not cost effective as general screening
tool in asymptomatic patients with
moderate to low risk
Not indicated in patients with abnormal
resting ECG such as BBB and LVH
Stress Nuclear Imaging
High cost but sensitive and specific test
for ischemia in men and women
Useful in presence of abnormal resting
Provides information regarding ischemia
as well as overall LV function
Significant potential for artifact
attenuation with breast tissue and
Stress Echocardiography
Moderately expensive test with
somewhat less sensitivity than nuclear
imaging, but somewhat higher
Accuracy is operator/interpreter
Information on ischemic wall motion
abnormalities as well as LV function
and valve disorders
Fast CT
Controversial modality at this time
Provides accurate evaluation of
calcification of coronary arteries, but
not direct relation to degree of
obstruction or ischemia
Some data demonstrate reasonable
correlation of calcium score with
coronary events, but not better than
other modalities
Technology for coronary imaging not
widely available at this time
Provides information both on plaque
burden and degree of obstruction
Limited to proximal 1/3 to 1/2 of
coronary arteries
Can be gated to demonstrate LV
Very expensive test
Coronary Angiography
Remains the gold standard tool for
both diagnosis and risk stratification of
coronary disease****
Very expensive test, along with the
highest morbidity and mortality
Current guidelines by the ACC/AHA do
not accept angiography as a screening
tool in moderate to low risk patients
General Principles
All patients with any risk factor should
receive ASA, 80 mg daily
All patients should receive fasting lipid
screen according to the NCEP guidelines
ECG should be performed on all patients
with symptoms of chest pain
Patients presenting with chest pain
Ifpresent at exam, the history is typical for
ischemia, and there is either high risk or
abnormal ECG the patient should be
admitted to hospital via the Emergency
In patients with established coronary disease
If the pain is similar to other ischemic episodes,
and the pattern is not progressive or more
severe, adjust medications and follow
In patients with established CAD, cont
If the pattern is rapidly progressing, or if
there are new associated symptoms or
increase in severity, adjust medication
and refer for angiography urgently
If the pattern is atypical, consider stress
testing (if baseline ECG is normal) or
nuclear/echo stress testing (if female or
baseline ECG abnormal)
Inpatients without established coronary
If presentation reflects typical pain in a high
risk patient, initiate medication and refer
for either angiography or stress testing.
If the presentation is atypical in a high risk
patient, refer for stress testing
If the presentation is typical, but the degree
is mild and the risk low, medication trial
with or without stress testing
If a prominent aortic systolic murmur
is heard which has not been
previously evaluated, referral for
echocardiography is indicated to
screen for critical aortic stenosis
There is no current recommendation
for the use of fast CT or MRI in the
evaluation of chest pain
ASA indicated in all cases of ischemia
and those with any risk factors.
Nitrates are first line therapy.
Nitrate free interval is essential (at least
8 hours per 24).
Little clinical difference between
Sublingual nitrates prn alone are not
adequate for established disease
BetaBlockers are highly effective (dec
contrx and HR = dec workload and O2
demand of heart)
Prime indication in patients with
Should be used in all patients post MI
May be used with caution in patients with
lung disease and diabetes
Withold in patients with reduced LV
functionbc can put them into CHF!! These
patients should be evaluated by specialist
Calcium Channel Blockers
Allthree types effective
Dihydropyridines not indicated post-MI
Verapamil and Diltiazem not indicated if
LV ejection fraction less than 40%
(Verapamil can cause even further
CHFmust have LV function)
Lipid lowering agents should be used to
meet the NCEP guidelines in all patients
Antioxidants such as Vitamin C and E,
retinoic acid, and Vitamin A have not
been shown to reduce event rates or
risk, and are no longer recommended
Estrogen Replacement therapy is no
longer indicated for coronary protection