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Angina Pectoris
Diagnosis/Definition
- Substernal chest discomfort, pressure, heaviness, squeezing or burning, radiating to the shoulders, arms (L > R), neck, jaw and epigastrium; it is brought on and exacerbated by exertion, relieved by rest and/or sublingual nitroglycerin (SL NTG).
- The discomfort usually lasts at least one minute and less than 15 minutes.
- Chest pain lasting only a few seconds is usually non-anginal.
- Pleuritic or positional pain and exquisite tenderness overlying the rib cage also suggest other etiologies.
Initial Diagnosis and Management
- History and physical exam.
- 12 lead electrocardiogram – PA and LAT CXR, if none obtained in recent past.
- Important to document the frequency and severity of anginal pattern; usage and response to SL NTG.
- Important to establish the presence or absence of rest angina.
- History of cold or emotion induced angina should be sought as this may suggest a vasospastic component.
- Important to determine whether prior diagnostic procedures to evaluate coronary disease (stress testing, cardiac catheterization) were performed.
- Precipitating factors like severe anemia, uncontrolled hypertension, dysrhythmia, hyperthyroidism and the use of cigarettes or birth control pills should be established.
- Aspirin, beta blockers, lipid management, ACE inhibitor therapy, calcium blockers, long acting nitrates, lipid therapy and SL NTG should be considered.
- Treadmill stress testing for stable angina will help to establish the diagnosis, prognosis and adequacy of medical therapy.
Ongoing Management and Objectives
- With incremental use of antianginal medications expect a decrease in frequency and severity of anginal episodes and increased exercise capacity.
- Risk factor modification is a very important aspect of management.
- Thallium stress testing, adenosine thallium, rest or exercise echocardiography most appropriately ordered in conjunction with the cardiologist.
Indications for Specialty Care Referral
Rapidly progressive anginal pattern with or without rest pain despite appropriate medical therapy.
Angina on activities of daily living despite medical therapy.
Prolonged episodes (greater than 20 minutes) of rest angina.
Early positive treadmill stress test.
New onset angina in individuals less than 45 years of age.
Return of angina post myocardial infarction.
Progressive angina or significant ischemic changes on graded exercise test post coronary artery bypass graft (CABG) or post percutaneous transluminal coronary angioplasty (PTCA) despite adequate medical therapy.
Criteria for Return to Primary Care
Patient successfully revascularized with either PTCA or CABG as determined by the cardiologist.
Completed cardiology consultation demonstrating stable angina requiring ongoing care that may be accomplished by the primary care physician.
Diagnosis of nonischemic chest pain.
