Stable angina
Background
- Chest pain due to cardiac ischemia
- Distinguish from unstable angina, which is defined as angina occurring at rest, for first time, or with increasing frequency/severity
Clinical Features
Classes (Canadian Cardiovascular Society Classification)[1]
| Classification | Symptoms | Limitation of Ordinary Activities |
| Grade I | With prolonged exertion | None |
| Grade II | Walking >2 blocks or climbing >1 flight of stairs | Slight |
| Grade III | Walking <2 blocks | Marked |
| Grade IV | With minimal activity or at rest | Cannot do any without symptoms |
Risk of ACS
Clinical factors that increase likelihood of ACS/AMI:[2][3]
- Chest pain radiating to both arms > R arm > L arm
- Chest pain associated with diaphoresis
- Chest pain associated with nausea/vomiting
- Chest pain with exertion
Clinical factors that decrease likelihood of ACS/AMI:[4]
- Pleuritic chest pain
- Positional chest pain
- Sharp, stabbing chest pain
- Chest pain reproducible with palpation
Gender differences in ACS
- Women with ACS:
- Less likely to be treated with guideline-directed medical therapies[5]
- Less likely to undergo cardiac catheterization[5]
- Less likely to receive timely reperfusion therapy[5]
- More likely to report fatigue, dyspnea, indigestion, nausea or vomiting, palpitations, or weakness,[5] although some studies have found fewer differences in presentation[6]
- More likely to delay presentation[5]
- Men with ACS:
- More likely to report central chest pain
Factors associated with delayed presentation[5]
- Female sex
- Older age
- Black or Hispanic race
- Low educational achievement
- Low socioeconomic status
Differential Diagnosis
Critical
- Acute Coronary Syndromes
- Aortic dissection
- Cardiac tamponade
- Pulmonary embolism
- Tension pneumothorax
- Esophageal perforation (Boerhhaave's syndrome)
- Coronary artery dissection
Emergent
- Pericarditis
- Myocarditis
- Pneumothorax
- Mediastinitis
- Cholecystitis
- Pancreatitis
- Cocaine-associated chest pain
- Myocardial rupture
Nonemergent
- Stable angina
- Asthma exacerbation
- Valvular Heart Disease
- Aortic Stenosis
- Mitral valve prolapse
- Hypertrophic cardiomyopathy
- Pneumonia
- Pleuritis
- Tumor
- Pneumomediastinum
- Esophageal Spasm
- Gastroesophageal Reflux Disease (GERD)
- Peptic Ulcer Disease
- Biliary Colic
- Muscle sprain
- Rib Fracture
- Arthritis
- Costochondritis
- Spinal Root Compression
- Thoracic outlet syndrome
- Herpes Zoster / Postherpetic Neuralgia
- Psychologic / Somatic Chest Pain
- Hyperventilation
- Panic attack
Evaluation
History[7]
- Assess:
- Changes in angina or heart failure symptoms
- Adherence to prescribed medications
- Changes in medications
- Medication side effects
Physical Examination[8]
- Resting heart rate and blood pressure
- Signs of heart failure
- New dysrhythmia
- New or worsening vascular bruits or murmurs
- Status of abdominal aorta
Management[9]
- Counsel regarding appropriate use of medications, nutrition, weight optimization, smoking cessation
Disposition
- If angina is stable and there is no other reason for admission, may discharge home for further management by family physician or cardiologist
External Links
References
- Campeau, L. Grading of angina pectoris. Circulation 1976; 54:5223
- Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454
- Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377
- Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077
- Mehta LS, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016; 133:916-947.
- Gimenez MR, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174(2):241-249.
- Mancini, G et al. (2014) Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease. Canadian Journal of Cardiology, 30(8).
- Mancini, G et al. (2014) Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease. Canadian Journal of Cardiology, 30(8).
- Mancini, G et al. Canadian Cardiovascular Society guidelines for the diagnosis and management of stable ischemic heart disease (2014). Canadian Journal of Cardiology, 30(8).,
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