Management of Stable Angina

Scott A. Phillips, M.D.AnMed Health Carolina Cardiology

Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made

regarding financial relationships with commercial interests within the last 12 months.

I , Scott Phillips have no relevant financial relationships or affiliations with commercial interests to disclose.

Cardiac Causes-Ischemic vs. Non-ischemic

Non-Cardiac Causes-Pulmonary, GI, Musculoskeletal, Dermatology

1. Chest Wall Pain• Sharp, Precisely localized• Reproducible: Palpation, movement

2. Pleuritic or Respiratory CP• Somatic pain, Sharp• Worse with breathing/coughing

3. Visceral CP• Poorly localized, aching, heaviness

Non-cardiac Chest Pain

Most common cause of non-cardiac chest pain

Causes:-Esophagitis/Gastritis-Ulcers-Reflux-Esophageal Spasm (can be relieved with Nitro)-Pancreatitis-Gall bladder

Pleuritic (worse with breathing/coughing) Sharp/stabbing pain

Causes:-Infections (bronchitis/pneumonia)-Pleural effusions (fluid around the lung)-Pulmonary Emboli (blood clots)-Pneumothorax (collapsed lung)-Malignancy

Costocondritis (inflammation of cartilage) Rib fracture Myalgia (muscle pains)

Pain is worse with movements. May be reproducible with palpation.

Shingles (Herpes Zoster)

Focal, dermatomal pain.

Constant, burning/tingling pain.

Pain starts several days before a rash is present.

Shingles

Ischemic:-Myocardial infarction (ACS) -Stable angina-Coronary vasospasm -Aortic stenosis -Hypertrophic cardiomyopathy

Non-ischemic:-Pericarditis -Aortic dissection

Causes:-congenital-calcification-rheumatic fever

Symptoms are typically exertional.

Often associated with signs of heart failure.

May also be associated with passing out (syncope).

Loud systolic murmur heard on exam.

Abnormal thickening of the heart muscle.

Hereditary

Causes outflow obstruction from the left ventricle.

Exertional chest pain, shortness of breath, and passing out, death.

Loud murmur on exam.

Sudden onset of SEVERE ripping/tearing chest pain

Radiates through to the back

Associated with high blood pressure.

Feeling of doom

Prinzmetal’s Angina

Spasms of the coronary arteries.

More common in women

Occurs at rest.

Can look like a heart attack on EKG.

Causes-Infections (Viral, tuberculosis)-Kidney failure-Autoimmune diseases-Radiation-Heart attacks (Dressler’s Syndrome)

Symptoms-Positional/pleuritic chest pain

Pericarditis

Coronary Artery Disease

Thrombus

Plaque rupture

Plaque Rupture

Aspirated blood clot and plaque during MI

Characteristics Location Severity Duration Associated symptoms Radiation of pain Triggers (exertion, emotional distress) Relieving features (rest, aspirin, nitro)

Chest pain (heavy, burning, tight, pressure, sharp, tingling, stabbing, throbbing)

Jaw/neck pain Arm pain/numbness Back pain Shortness of breath Nausea/vomiting, hiccups Sweating

Typical Anginal Pain Distribution

Class I

Class II

Class III

Class IV

No angina with ordinary physical activity

Angina with strenuous/prolonged exertionEarly-onset, limitation of ordinary activity (2 blocks/1 flight)

Marked limitation of ordinary activity

Inability to carry out any physical activity without angina

Angina occurs at rest

Pretest Probability

Does the pt fit into one of the following?1. Noncardiac CP and low pretest probability

2. Diagnosis of angina is established (high pretest prob)

3. Diagnosis is still not clear…(intermediate pretest prob)

• No further testing needed.

• Pt does not have angina

• No further diagnostic testing needed.

• Pt needs risk stratification for prognosis

• Consider the following tests to make a diagnosis…

Algorithm for Evaluation and Management of Patients Suspected of Having ACS.

Anderson J L et al. Circulation. 2011;123:e426-e579

Copyright © American Heart Association, Inc. All rights reserved.

71 w/m with 2 month h/o exertional chest pressure.

Presented to PCP office with worsening of symptoms during exertion.

PMHx: Hyperlipidemia, HTN, CRI, ED

Meds: Crestor, Prilosec, Cialis

Allergies: NKDA

FHx: None

SocHx: smoker

Exam: Afeb, 130/82, 85, 16, (Normal exam)

Labs: BUN 20, Cr 1.0, Gluc 99, WBC 5, HCT 43, Plt 140

CXR: normal

63 w/m with 3 month h/o mild intermitent exertional chest pain.

Worse and more frequent over past week.

Severe episode with SOB prompting first time visit to PCP’s office.

PMHx: HTN

Meds: Lisinopril, ASA.

Allergies: NKDA

FHx: CVA

SocHx: non-smoker, rare EtOH, no illicits, pharmacist.

Exam: Afeb, 149/98, 115, 18, 95% 2L NC

NAD

Tachycardic, 1/6 harsh syst murmur RUSB, JVD to jaw

Bilateral rales half way up lung fields.

Trace pedal edema, warm, 2+ pulses

WBC 12, HCT 43, Plt 333

BUN 21, Cr 0.8, Gluc 183

HgA1C 7.8

Chol 177, Trig 161, LDL 115, HDL 30

Trop 0.87, 1.03

CXR: pulmonary edema

ECHO: EF 20%, mild AS

86 w/m with 6 month h/o exertional left sided chest pressure and DOE.

Worsening over past 2 weeks.

Presents to PCP after 2 episodes of resting pain.

PMHx: HTN, COPD, Parkinson’s, BPH, chronic anemia, OA.

Meds: ASA, lisinopril, calcium, eye drops, combivent.

Allergies: NKDA

FHx: N/C

SocHx: Lives with care taker, 3 sons, remains fairly active, non-smoker.

Exam: Afeb, 105/70, 70, 14

Thin with mild Parkinsonian features.

2/6 syst murmur LSB.

Labs: BUN 19, Cr 0.5, WBC 6, HCT 36, MCV 92, Plt 188

Imaging: CXR normal

76 w/f with 1 month h/o intermittent non-exertional burning mid epigastric/substernal chest discomfort partially relieved with TUMS.

PMHx: HTN, hyperlipidemia, borderline DM

PSHx: cholecystectomy and hysterectomy.

Meds: ASA, Toprol, lisinopril, pravastatin.

Allergies: NKDA

FHx: CAD (father/brother)

SocHx: Quit smoking 25 yrs ago.

Exam: Afeb, 164/92 (didn’t take a.m. meds), 59, 16

Otherwise normal exam.

Labs: Normal

Imaging: CXR normal.

Questions ??????