History

Fact Explanation
Chest pain Patients complain of retrosternal constricting type of chest pain or discomfort. It is commonly seen with exertion but may occur at rest as well. Pain radiates to the left shoulder and or to the left jaw. In order to diagnose angina all the following three criteria should be met. Pain should be substernal, symptoms are precipitated by physical or emotional stress and they usually respond to rest and or to nitrates. Chest pain in angina pectoris does not last more than 10 minutes. [2,5] According to the New York Heart Association (NYHA) functional classification, patients who develop angina only with vigorous exercise is classified under the class I. if angina occurs with slightly more vigorous activity than usual or if it is prolonged it is classified under class II. Angina occurring with normal daily activities is class III and if occurs at rest it is class IV. [1]
Reduced exercise tolerance Patients develop ischemic chest pain with exercise, hence they have reduced exercise tolerance. [3]
Palpitations Patients with vasospastic angina can have ventricular arrhythmia. [4]
Risk factors of ischemic heart disease Hyperlipidemia, diabetes, hypertension, smoking, sedentary life style, obesity and positive family history of ischemic heart disease are recognized risk factors for ischemic heart disease. [6]
References
  1. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part I. Risk assessment. Am Fam Physician [online] 1999 Dec, 60(9):2543-52 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10605990
  2. AGEWALL STEFAN. Nye retningslinjer for angina pectoris. Tidsskriftet [online] 2014 December, 134(5):510-510 [viewed 21 June 2014] Available from: doi:10.4045/tidsskr.13.1552
  3. GARDNER AW, MONTGOMERY PS, RITTI-DIAS RM, THADANI U. Exercise performance, physical activity, and health-related quality of life in participants with stable angina. Angiology [online] 2011 Aug, 62(6):461-6 [viewed 21 June 2014] Available from: doi:10.1177/0003319711399897
  4. MATSUE Y, SUZUKI M, NISHIZAKI M, HOJO R, HASHIMOTO Y, SAKURADA H. Clinical implications of an implantable cardioverter-defibrillator in patients with vasospastic angina and lethal ventricular arrhythmia. J Am Coll Cardiol [online] 2012 Sep 4, 60(10):908-13 [viewed 21 June 2014] Available from: doi:10.1016/j.jacc.2012.03.070
  5. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001
  6. ROETERS VAN LENNEP J. Risk factors for coronary heart disease: implications of gender. [online] 2002 February, 53(3):538-549 [viewed 22 June 2014] Available from: doi:10.1016/S0008-6363(01)00388-1

Examination

Fact Explanation
Obesity Obesity is a risk factor for the development of ischemic heart diseases. Both Body Mass Index (BMI) and waist circumference should be measured. [1,6]
Tachycardia or arrhythmia Patients often have arrhythmia induced by myocardial ischemia. [2,3]
Hypertension Patients can have elevated blood pressure, which is a risk factor for the development of angina pectoris. [4]
Pheripheral stigmata of hyperlipidemia Xanthelasma, xanthomata and corneal arcus are peripheral stigmata of hyperlipidemia. [5]
References
  1. WłODARCZYK A, STROJEK K. Glucose intolerance, insulin resistance and metabolic syndrome in patients with stable angina pectoris. Obesity predicts coronary atherosclerosis and dysglycemia. Pol Arch Med Wewn [online] 2008 Dec, 118(12):719-26 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19202950
  2. MATSUE Y, SUZUKI M, NISHIZAKI M, HOJO R, HASHIMOTO Y, SAKURADA H. Clinical implications of an implantable cardioverter-defibrillator in patients with vasospastic angina and lethal ventricular arrhythmia. J Am Coll Cardiol [online] 2012 Sep 4, 60(10):908-13 [viewed 21 June 2014] Available from: doi:10.1016/j.jacc.2012.03.070
  3. MARTIN J, SANFILIPPO F, BRADLOW W, SABHARWAL NK. Severe vasospastic angina complicated by multiple pulseless electrical activity arrests. Lancet [online] 2013 Aug 3, 382(9890):478 [viewed 21 June 2014] Available from: doi:10.1016/S0140-6736(13)61096-X
  4. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part I. Risk assessment. Am Fam Physician [online] 1999 Dec, 60(9):2543-52 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10605990
  5. PIETROLEONARDO L, RUZICKA T. Skin manifestations in familial heterozygous hypercholesterolemia. Acta Dermatovenerol Alp Pannonica Adriat [online] 2009 Dec, 18(4):183-7 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20043058
  6. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001

Differential Diagnoses

Fact Explanation
Myocardial infarction Patients with myocardial infarction also presents with severe constricting type of chest pain which radiates to the left arm and jaw. Pain in myocardial infarction is associated with nausea, vomiting and sweating as well. [10]
Aortic stenosis Aortic stenosis can also present with angina on exertion. [1]
Costochondritis This is inflammation of costochondral junctions. Often a self-limiting condition. Pain in the chest is exacerbated by deep breathing and strenuous exercise. [2]
Herpes zoster Herpes zoster in the thoracic dermatomes also produces chest pain, itching, paresthesia and dysesthesia over the affected dermatome. Examination will reveal the vesicles in the affected dermatome. [3,9]
Hyperthyroidism Patients with hyperthyroidism can present with angina like chest pain. [4]
Hyperviscosity syndrome Hyperviscosity is a precipitant cause of angina. [5]
Hypotension Hypotension can cause secondary angina as it reduces the coronary blood flow. [5]
Mitral valve disease Mitral regurgitation and mitral valve prolapse can precipitate angina. [6]
Pancreatitis Upper abdominal (epigastric or paraumbilical) pain, with associated nausea and vomiting. Abdominal pain radiates to the back typically, but may radiate to the chest, flanks, and lower abdomen as well. [8]
Pulmonary embolism Patients present with dyspnea, pleuritic chest pain and haemoptysis. [7]
Anemia Iron deficiency anemia can present with angina. [11]
References
  1. VAN DEN BRINK RB, BOUMA BJ. A patient with aortic stenosis and angina pectoris. Eur Heart J [online] 2012 Jun, 33(12):1479 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehr476
  2. PROULX AM, ZRYD TW. Costochondritis: diagnosis and treatment. Am Fam Physician [online] 2009 Sep 15, 80(6):617-20 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19817327
  3. DWORKIN R. H., JOHNSON R. W., BREUER J., GNANN J. W., LEVIN M. J., et al. Recommendations for the Management of Herpes Zoster. Clinical Infectious Diseases [online] 2007 January, 44(Supplement 1):S1-S26 [viewed 21 June 2014] Available from: doi:10.1086/510206
  4. RESNEKOV L, FALICOV RE. Thyrotoxicosis and lactate-producing angina pectoris with normal coronary arteries. Br Heart J [online] 1977 Oct, 39(10):1051-7 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/911554
  5. BRAUNWALD E.. Unstable Angina : An Etiologic Approach to Management. Circulation [online] 1998 November, 98(21):2219-2222 [viewed 21 June 2014] Available from: doi:10.1161/01.CIR.98.21.2219
  6. BAXTER RH, REID JM, MCGUINESS JB, STEVENSON JG. Relation of angina to coronary artery disease in mitral and in aortic valve disease. Br Heart J [online] 1978 Aug, 40(8):918-922 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC483508
  7. RIEDEL M.. VENOUS THROMBOEMBOLIC DISEASE: Acute pulmonary embolism 1: pathophysiology, clinical presentation, and diagnosis. [online] 2001 February, 85(2):229-240 [viewed 21 June 2014] Available from: doi:10.1136/heart.85.2.229
  8. CARROLL JK, HERRICK B, GIPSON T, LEE SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1513-20 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555143
  9. NIKLAUS H. MUELLER, DONALD H. GILDEN, MARIA A. NAGEL. Varicella Zoster Virus Infection: Clinical Features, Molecular Pathogenesis of Disease, and Latency. Neurol Clin. [online] Aug 2008; 26(3): 675-viii. [viewed 21 June 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754837/
  10. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 21 June 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  11. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001

Investigations - for Diagnosis

Fact Explanation
Resting electrocardiogram (ECG) [1] Resting ECG can be normal in patients with angina pectoris. ECG may show evidence of left ventricular hypertrophy. [2]
Stress ECG This is more sensitive and specific than the resting ECG. Stress ECG can identify inducible ischemia. [2] Stress can be induced by either graded exercise or with pharmacological substances like digoxin. [3]
Coronary angiography This visualizes the lesion and the degree of stenosis. This is considered an alternative to stress ECG test. [2]
Stress echocardiography Regional wall motion abnormalities and wall thickening can be detected after stress. If subendocardial ischemia is induced by exercise, cardiac contractility decreases. Wall motion abnormalities appear before the onset of ischemic ECG changes. So stress echocardiography is better than the ECG stress test. [1]
References
  1. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part I. Risk assessment. Am Fam Physician [online] 1999 Dec, 60(9):2543-52 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10605990
  2. AGEWALL STEFAN. Nye retningslinjer for angina pectoris. Tidsskriftet [online] 2014 December, 134(5):510-510 [viewed 21 June 2014] Available from: doi:10.4045/tidsskr.13.1552
  3. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001

Investigations - Fitness for Management

Fact Explanation
Full blood count Anemia is a precipitant cause for the development of angina, which is correctable. [2]
Renal function test This is indicated for baseline evaluation of patients’ fitness. [2]
Exercise stress test Can evaluate the patient’s exercise tolerance and degree of myocardial ischemia. It can determine the severity of coronary artery obstruction and hence the prognosis. [1] Horizontal or downsloping ST segment depression of 1mm or more is considered as positive. [3]
Nuclear stress test Patients who are unable to do exercise can be subjected to nuclear stress test. Dobutamine, adenosine or dipyridamole is used to induce cardiac stress. [1]
Echocardiogram Determines the ejection fraction. If the ejection fraction is low, surgical revascularization is preferred over medical management. Echocardiogram also detects regional wall motion abnormalities, which are indicative of reversible ischemia. [1]
Chest X-ray [1] Aids in diagnosing heart failure. Presence of alveolar edema, Kerley B lines, cardiomegaly and upper lobe diversion are suggestive of heart failure.
References
  1. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part I. Risk assessment. Am Fam Physician [online] 1999 Dec, 60(9):2543-52 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10605990
  2. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001

Investigations - Followup

Fact Explanation
Fasting plasma glucose Assessment of fasting plasma glucose is needed to diagnose or to exclude the presence of diabetes, which is a common co-morbidity. [1]
Lipid profile Total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, and triglycerides should be assessed in all patients with ischemic heart diseases. [1]
References
  1. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal [online] 2006 March, 27(11):1341-1381 [viewed 21 June 2014] Available from: doi:10.1093/eurheartj/ehl001

Management - General Measures

Fact Explanation
Health education Patients should be advised about the importance of adherence to a healthy lifestyle, with adequate exercise, weight reduction and dietary modifications. The known precipitating factors of angina should be better avoided and if present anemia, valvular heart diseases and arrhythmia should be treated. Patients with cardiovascular comorbidities like diabetes, hypertension and hypercholesterolemia should be taught about the importance of control of comorbidities. [1,2]
Dietary modifications Patients are advised to take a balanced diet with variety of food items. Fat and cholesterol rich food is better avoided. Calorie intake from fats should be less than 30% of the total. Dietary fibers should be increased. Complex carbohydrates are preferred to simple carbohydrates. Consumption of salt should be reduced (less than 2.4 g/day). Alcohol consumption should be stopped or at least cut down to safe limits. [3]
Physical exercise It is recommended to exercise for 30 minutes preferably daily or at least most days of the week. Brisk walking at a rate of 3 to 4 miles per hour, swimming, cycling, occupational or recreational activities and yard or household work are recommended exercises. [4]
Management of hypertension Hypertension is a risk factor for the development of ischemic heart diseases. In patients with hypertension and angina beta-blockers are considered as the first line antihypertensive in treatment. [2]
Management of diabetes Diabetes is a comorbid risk factor for the development of ischemic heart disease. [1]
References
  1. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part II. Medical management of chronic stable angina. Am Fam Physician [online] 2000 Jan 1, 61(1):129-38 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10643954
  2. PFLIEGER M, WINSLOW BT, MILLS K, DAUBER IM. Medical management of stable coronary artery disease. Am Fam Physician [online] 2011 Apr 1, 83(7):819-26 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524048
  3. KRAUSS R. M., DECKELBAUM R. J., ERNST N., FISHER E., HOWARD B. V., KNOPP R. H., KOTCHEN T., LICHTENSTEIN A. H., MCGILL H. C., PEARSON T. A., PREWITT T. E., STONE N. J., VAN HORN L., WEINBERG R.. Dietary Guidelines for Healthy American Adults: A Statement for Health Professionals From the Nutrition Committee, American Heart Association. Circulation [online] 1996 October, 94(7):1795-1800 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.94.7.1795
  4. MYERS J.. Exercise and Cardiovascular Health. [online] 2003 January, 107(1):2e-5 [viewed 22 June 2014] Available from: doi:10.1161/​01.CIR.0000048890.59383.8D

Management - Specific Treatments

Fact Explanation
Coronary revascularization [1] Coronary revascularization is preferred over medical management if the patient has left ventricular dysfunction and three-vessel disease or left main coronary artery disease. Coronary artery bypass grafts, angioplasty and percutaneous techniques achieve coronary revascularization. [1,4]
Nitrates A potent venodilator, which decreases venous return and reduces the preload. This reduces the work load on myocytes and hence the oxygen demand. Nitrates also dilate the coronary arteries and improves myocardial perfusion. Sublingual, buccal, oral, intravenous and topical preparations are available. [2,3]
Beta-adrenergic blockers Beta-adrenergic blockers block beta1 and beta2 receptors on myocytes and decreases the heart rate and the force of contraction. This reduces the myocardial oxygen demand. Once the heart rate is reduced the diastole prolongs hence the duration of coronary perfusion also prolongs. Cardioselective beta blockers (acebutolol, atenolol, betaxolol, metoprolol) mainly block beta1 adrenergic receptors in the heart, hence they have minimal effects on airway contractility. [2]
Calcium Channel Blockers (CCB) CCBs causes vascular smooth muscle relaxation and vasodilatation. CCBs also inhibit the sinus and atrioventricular nodes and reduce the heart rate. [2,3]
Antiplatelet drugs Aspirin inhibits the cyclooxygenase enzyme in the vascular endothelium and in the platelets, thereby inhibits the synthesis of prostaglandins, mainly thromboxane A2. Thromboxane A2 is a potent vasoconstrictor and platelet activator. This prevents platelet aggregation and vasoconstriction. Clopidogrel is also an antiplatelet drug which is also used in treatment. [2,3]
Lipid-lowering therapy This is effective in patients with hypercholesterolemia, which is a significant risk factor. [2,3]
Antioxidants Antioxidants like vitamins A and E are believed to play a role in decreasing adverse cardiovascular events. [2]
Electrical neuromodulation This is proved to be useful in refractory angina pectoris. In this method of treatment and electrode is implanted in the epidural space for pain relief. This is preferred if other treatment modalities cannot be used. [5]
References
  1. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part I. Risk assessment. Am Fam Physician [online] 1999 Dec, 60(9):2543-52 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10605990
  2. ZANGER DR, SOLOMON AJ, GERSH BJ. Contemporary management of angina: part II. Medical management of chronic stable angina. Am Fam Physician [online] 2000 Jan 1, 61(1):129-38 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10643954
  3. PFLIEGER M, WINSLOW BT, MILLS K, DAUBER IM. Medical management of stable coronary artery disease. Am Fam Physician [online] 2011 Apr 1, 83(7):819-26 [viewed 21 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524048
  4. AGEWALL STEFAN. Nye retningslinjer for angina pectoris. Tidsskriftet [online] 2014 December, 134(5):510-510 [viewed 21 June 2014] Available from: doi:10.4045/tidsskr.13.1552
  5. LEE SH, JEONG HJ, JEONG SH, LEE HG, CHOI JI, YOON MH, KIM WM. Spinal Cord Stimulation for Refractory Angina Pectoris -A Case Report- Korean J Pain [online] 2012 Apr, 25(2):121-125 [viewed 21 June 2014] Available from: doi:10.3344/kjp.2012.25.2.121