Chest Pain / Angina Pectoris: Difference between revisions

Jump to navigation Jump to search
no edit summary
No edit summary
No edit summary
 
(33 intermediate revisions by 2 users not shown)
Line 1: Line 1:
[[File:Heart_coronary_artery.jpg|thumb|400px|An epicardial coronary artery with a atherosclerotic narrowing]]
Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved
Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved
by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease or aortic valve stenosis.  
by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease or aortic valve stenosis.  
Line 7: Line 8:
A complete history and physical examination are essential to support the diagnosis (stable) angina pectoris and to exclude other (acute) causes of chest pain such as an acute coronary syndrome, aortic dissection, arrhythmias, pulmonary embolism, (tension) pneumothorax or pneumonia, gastroesophageal reflux or spams, hyperventilation or musculoskeletal pain. <Cite>REFNAME2</Cite>  In addition, laboratory tests and specific cardiac investigations are often necessary.
A complete history and physical examination are essential to support the diagnosis (stable) angina pectoris and to exclude other (acute) causes of chest pain such as an acute coronary syndrome, aortic dissection, arrhythmias, pulmonary embolism, (tension) pneumothorax or pneumonia, gastroesophageal reflux or spams, hyperventilation or musculoskeletal pain. <Cite>REFNAME2</Cite>  In addition, laboratory tests and specific cardiac investigations are often necessary.


==History:==
==History==
[[File:Chest_pain_areas.svg|thumb|Typical chest pain is retrosternal. Pain may radiate to the arms, jaw, and / or back.]]
Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. <Cite>REFNAME3</Cite> Some patients only complain about abdominal pain so the presentation can be aspecific. <Cite>REFNAME4</Cite>, <Cite>REFNAME5</Cite>
Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. <Cite>REFNAME3</Cite> Some patients only complain about abdominal pain so the presentation can be aspecific. <Cite>REFNAME4</Cite>, <Cite>REFNAME5</Cite>


Line 14: Line 16:
Another way to relieve pain is by administration of nitro-glycerine. Nitro-glycerine spray is a vasodilator which reduces venous return to the heart and therefore decreases the workload and therefore oxygen demand. It also dilates the coronary arteries and increases coronary blood flow. <Cite>REFNAME7</Cite> The response to nitro-glycerine is however not specific for angina pectoris, a similar response may be seen with oesophageal spasm or other gastrointestinal problems because nitro-glycerine relaxes smooth muscle tissue. <Cite>REFNAME8</Cite>
Another way to relieve pain is by administration of nitro-glycerine. Nitro-glycerine spray is a vasodilator which reduces venous return to the heart and therefore decreases the workload and therefore oxygen demand. It also dilates the coronary arteries and increases coronary blood flow. <Cite>REFNAME7</Cite> The response to nitro-glycerine is however not specific for angina pectoris, a similar response may be seen with oesophageal spasm or other gastrointestinal problems because nitro-glycerine relaxes smooth muscle tissue. <Cite>REFNAME8</Cite>


Depending on the characteristics, chest pain can be identified as typical angina, atypical angina or non-cardiac chest pain, see table 1   
Depending on the characteristics, chest pain can be identified as typical angina, atypical angina or non-cardiac chest pain, see Table 1.  


{| class="wikitable" border="1"
{| class="wikitable" border="1" width="600px"
|-
|-
! align="center" colspan="2" | Table 1. Clinical classification of chest pain <Cite>REFNAME17</Cite>
! align="center" colspan="2" | Table 1. Clinical classification of chest pain <Cite>REFNAME17</Cite>
Line 24: Line 26:
*Substernal chest discomfort of characteristic quality and duration
*Substernal chest discomfort of characteristic quality and duration
*Provoked by exertion or emotional stress
*Provoked by exertion or emotional stress
*Relieved by rest and/or GTN
*Relieved by rest and/or nitroglycerine
|-
|-
| valign="top"|Atypical angina (probable)
| valign="top"|Atypical angina (probable)
Line 33: Line 35:
|}
|}


The classification of chest pain in combination with age and sex is helpful in estimating the pretest likelihood of angiographically significant coronary artery disease, see table 2.  
The classification of chest pain in combination with age and sex is helpful in estimating the pretest likelihood of angiographically significant coronary artery disease, see Table 2.  


{| class="wikitable" border="1"
{| class="wikitable" border="1" width="600px"
|-
|-
! align="left" colspan = "7" | Table 2. Pretest Probabilities of >=50% Diameter Stenotic Coronary Artery Disease in Patients with Chest Pain as Shown in the American College of Cardiology/American Association Guidelines for Management of Chronic Stable Angina <Cite>REFNAME20</Cite>
! align="left" colspan = "7" | Table 2. Clinical pre-test probabilities <sup>a</sup> in patients with stable chest pain symptoms. <Cite>REFNAME20</Cite>
|-  
|-  
| align="center" |
| align="center"|
| align="center" colspan="2" | Nonanginal Chest Pain, %
| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Typical angina</b>
| align="center" colspan="2" | Atypical Angina, %
| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Atypical angina</b>
| align="center" colspan="2" | Typical Angina, %
| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Non-anginal pain</b>
|-
|-
| align="center" | Age, y
! Age
| align="center" | Men
! Men
| align="center" | Women
! Women
| align="center" | Men  
! Men  
| align="center" | Women
! Women
| align="center" | Men
! Men
| align="center" | Women
! Women
|-
|-
| align="center" | 30-39
! 30-39
| align="center" | 4
| align="center" bgcolor="#F0F8FF" | 59
| align="center" | 2
| align="center" bgcolor="#F0F8FF" | 28
| align="center" | 34
| align="center" bgcolor="#F0F8FF" | 29
| align="center" | 12
| align="center" bgcolor="#FFFFFF" | 10
| align="center" | 76
| align="center" bgcolor="#F0F8FF" | 18
| align="center" | 26
| align="center" bgcolor="#FFFFFF" | 5
|-
|-
| align="center" | 40-49
! 40-49
| align="center" | 13
| align="center" bgcolor="#FFCCCC" | 69
| align="center" | 3
| align="center" bgcolor="#F0F8FF" | 37
| align="center" | 51
| align="center" bgcolor="#F0F8FF" | 38
| align="center" | 22
| align="center" bgcolor="#FFFFFF" | 14
| align="center" | 87
| align="center" bgcolor="#F0F8FF" | 25
| align="center" | 55
| align="center" bgcolor="#FFFFFF" | 8
|-
|-
| align="center" | 50-59
! 50-59
| align="center" | 20
| align="center" bgcolor="#FFCCCC" | 77
| align="center" | 7
| align="center" bgcolor="#F0F8FF" | 47
| align="center" | 65
| align="center" bgcolor="#F0F8FF" | 49
| align="center" | 31
| align="center" bgcolor="#F0F8FF" | 20
| align="center" | 93
| align="center" bgcolor="#F0F8FF" | 34
| align="center" | 73
| align="center" bgcolor="#FFFFFF" | 12
|-
|-
| align="center" | 60-69
! 60-69
| align="center" | 27
| align="center" bgcolor="#FFCCCC" | 84
| align="center" | 14
| align="center" bgcolor="#F0F8FF" | 58
| align="center" | 72
| align="center" bgcolor="#F0F8FF" | 59
| align="center" | 51
| align="center" bgcolor="#F0F8FF" | 28
| align="center" | 94
| align="center" bgcolor="#F0F8FF" | 44
| align="center" | 86
| align="center" bgcolor="#F0F8FF" | 17
|-
! 70-79
| align="center" bgcolor="#FF69B4" | 89
| align="center" bgcolor="#FFCCCC" | 68
| align="center" bgcolor="#FFCCCC" | 69
| align="center" bgcolor="#F0F8FF" | 37
| align="center" bgcolor="#F0F8FF" | 54
| align="center" bgcolor="#F0F8FF" | 24
|-
! >80
| align="center" bgcolor="#FF69B4" | 93
| align="center" bgcolor="#FFCCCC" | 76
| align="center" bgcolor="#FFCCCC" | 78
| align="center" bgcolor="#F0F8FF" | 47
| align="center" bgcolor="#F0F8FF" | 65
| align="center" bgcolor="#F0F8FF" | 32
|-
| colspan = "7" bgcolor="#FFFFFF"|
|-
! colspan = "7" | ECG = electrocardiogram; PTP = pre-test probability; SCAD = stable coronary artery disease.
|-
| colspan = "7" bgcolor="#FFFFFF" | <b><sup>a</sup></b> Probabilities of obstructive coronary disease shown reflect the estimates for patients aged 35, 45, 55, 65, 75 and 85 years.
*Groups in <i>white boxes</i> have a PTP <15% and hence can be managed without further testing.
*Groups in <i>blue boxes</i> have a PTP of 15–65%. They could have an exercise ECG if feasible as the initial test. However, if local expertise and availability permit a non-invasive imaging based test for ischaemia this would be preferable given the superior diagnostic capabilities of such tests. In young patients radiation issues should be considered.
*Groups in <i>light pink boxes</i> have PTPs between 66–85% and hence should have a non-invasive imaging functional test for making a diagnosis of SCAD.
*In groups in <i>dark pink boxes</i> the PTP is >85% and one can assume that SCAD is present. They need risk stratification only.
|}
|}


The severity of complaints can be classified according to the Canadian Cardiovascular Society as shown in table 3
The severity of complaints can be classified according to the Canadian Cardiovascular Society as shown in Table 3


{| class="wikitable" border="1"
{| class="wikitable" border="1" width="600px"
|-
|-
! colspan="2" | Table 3. Classification of angina severity according to the Canadian Cardiovascular Society
! colspan="2" | Table 3. Classification of angina severity according to the Canadian Cardiovascular Society
|-
|-
| width="100" align="left" | ''Class''
! width="100"| ''Class''
| align="left" | ''Level of Symptoms''
| ''Level of Symptoms''
|-
|-
| valign="top" align="left" | Class I
! valign="top"| Class I
| align="left" | 'Ordinary activity does not cause angina'
| 'Ordinary activity does not cause angina'
Angina with strenuous or rapid or prolonged exertion only
Angina with strenuous or rapid or prolonged exertion only
|-
|-
| valign="top" align="left" | Class II
! valign="top"| Class II
| align="left" | 'Slight limitation of ordinary activity'
| 'Slight limitation of ordinary activity'
Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or only during the first few hours after awakening
Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or only during the first few hours after awakening
|-
|-
| valign="top" align="left" | Class III
! valign="top"| Class III
| align="left" | 'Marked limitation of ordinary physical activity'
| 'Marked limitation of ordinary physical activity'
Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions
Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions
|-
|-
| valign="top" align="left" | Class IV
! valign="top"| Class IV
| align="left" | 'Inability to carry out physical activity without discomfort' or 'angina at rest'
| 'Inability to carry out physical activity without discomfort' or 'angina at rest'
|}
|}


During angina pectoris ‘vegetative’ symptoms can occur, including sweating, nausea, paleface, anxiety and agitation. This is probably caused by the autonomic nerve system in reaction to stress. <Cite>REFNAME9</Cite>
During angina pectoris ‘vegetative’ symptoms can occur, including sweating, nausea, paleface, anxiety and agitation. This is probably caused by the autonomic nerve system in reaction to stress. <Cite>REFNAME9</Cite>


Finally, it is important to differentiate unstable angina (indicating an acute coronary syndrome or even myocardial infarction requiring urgent treatment) from stable angina. Unstable angina typically is severe, occurs without typical provocation and does not disappear with rest, and has a longer duration than stable angina. It is important to initiate prompt treatment in these patients, as described in the acute coronary syndromes chapter.  
Finally, it is important to differentiate unstable angina (indicating an acute coronary syndrome or even myocardial infarction requiring urgent treatment) from stable angina. Unstable angina typically is severe, occurs without typical provocation and does not disappear with rest, and has a longer duration than stable angina. It is important to initiate prompt treatment in these patients, as described in the acute coronary syndromes chapter.


==Physical Examination:==
==Physical Examination==
   
   
There are no specific signs in angina pectoris. Physical examination of a patient with (suspected) angina pectoris is important to assess the presence of hypertension,
There are no specific signs in angina pectoris. Physical examination of a patient with (suspected) angina pectoris is important to assess the presence of hypertension,
valvular heart disease (in particular aortic valve stenosis) or hypertrophic obstructive cardiomyopathy. It should include the body-mass index, evidence of non-coronary vascular disease which may be asymptomatic and other signs of co-morbid conditions. E.g.: absence of palpable pulsations in the dorsal foot artery is associated with an 8 fold increase in the likelihood of coronary artery disease.
valvular heart disease (in particular aortic valve stenosis) or hypertrophic obstructive cardiomyopathy. It should include the body-mass index, evidence of non-coronary vascular disease which may be asymptomatic and other signs of co-morbid conditions. E.g.: absence of palpable pulsations in the dorsal foot artery is associated with an 8 fold increase in the likelihood of coronary artery disease.


==Electrocardiogram (ECG):==
==Electrocardiogram (ECG)==
The electrocardiogram (ECG) is an important tool to differentiate between unstable angina (acute coronary syndrome) and stable angina in addition to the patient’s history. Patients with unstable angina pectoris are likely to show abnormalities on the ECG at rest, in particular ST-segment deviations.  
The electrocardiogram (ECG) is an important tool to differentiate between unstable angina (acute coronary syndrome) and stable angina in addition to the patient’s history. Patients with unstable angina pectoris are likely to show abnormalities on the ECG at rest, in particular ST-segment deviations.  
Although a resting ECG may show signs of coronary artery disease such as pathological Q-waves indicating a previous MI or other abnormalities, many patients with stable angina pectoris have a normal ECG at rest. Therefore exercise ECG testing may be necessary to show signs of myocardial ischemia. <Cite>REFNAME10</Cite>
Although a resting ECG may show signs of coronary artery disease such as pathological Q-waves indicating a previous MI or other abnormalities, many patients with stable angina pectoris have a normal ECG at rest. Therefore exercise ECG testing may be necessary to show signs of myocardial ischemia. <Cite>REFNAME10</Cite>
Line 129: Line 157:


==Stress Testing in Combination with Imaging==
==Stress Testing in Combination with Imaging==
Some patients are unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities the exercise ECG is associated with low sensitivity and specificity. If the ECG made during exercise testing does not show any abnormalities myocardial ischemia becomes unlikely as cause of the complaints. If the diagnosis is still in doubt, the following additional tests may be performed.  
Some patients are unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities the exercise ECG is associated with low sensitivity and specificity.  
 
{| class="wikitable" border="1" width="600px"
|-
|colspan = "7" | <b>Table 4. Characteristics of tests commonly used to diagnose the presence of coronary artery disease. <Cite>REFNAME20</Cite></b>
|-
| bgcolor="#FFFFFF" rowspan="2"|
|align="center" colspan="2" bgcolor="#FFFFFF" | <b>Diagnosis of CAD</b>
|-
| align="center" bgcolor="#FFFFFF" | <b>Sensitivity (%)</b>
| align="center" bgcolor="#FFFFFF" | <b>Specificity (%)</b>
|-
| <b>Exercise ECG <sup>a, 91, 94, 95</sup></b>
!45–50
!85–90
|-
| <b>Exercise stress echocardiography <sup>96</sup></b>
!80–85
!80–88
|-
| <b>Exercise stress SPECT <sup>96-99</sup></b>
!73–92
!63–87
|-
| <b>Dobutamine stress echocardiography <sup>96</sup></b>
!79–83
!82–86
|-
| <b>Dobutamine stress MRI <sup>b,100</sup></b>
!79–88
!81–91
|-
| <b>Vasodilator stress echocardiography <sup>96</sup></b>
!72–79
!92–95
|-
| <b>Vasodilator stress SPECT <sup>96, 99</sup></b>
!90–91
!75–84
|-
| <b>Vasodilator stress MRI <sup>b,98, 100-102</sup></b>
!67–94
!61–85
|-
| <b>Coronary CTA <sup>c,103-105</sup></b>
!95–99
!64–83
|-
| <b>Vasodilator stress PET <sup>97, 99, 106</sup></b>
!81–97
!74–91
|-
| colspan="3" bgcolor="#FFFFFF"| <b>CAD</b> = coronary artery disease; <b>CTA</b> = computed tomography angiography; <b>ECG</b> = electrocardiogram; <b>MRI</b> = magnetic resonance imaging; <b>PET</b> = positron emission tomography; <b>SPECT</b> = single photon emission computed tomography.
|-
| colspan="3"|<b><sup>a</sup></b> Results without/with minimal referral bias.
 
<b><sup>b</sup></b> Results obtained in populations with medium-to-high prevalence of disease without compensation for referral bias.
 
<b><sup>c</sup></b> Results obtained in populations with low-to-medium prevalence of disease.
|}
 
[[File:Algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.svg|thumb|right|500px|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]]
 
If the ECG made during exercise testing does not show any abnormalities myocardial ischemia becomes unlikely as cause of the complaints. If the diagnosis is still in doubt, the following additional tests may be performed.  
#Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine.
#Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine.
#Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite>
#Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite>
#Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite>  
#Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite>  


The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent complications including mortality based on risk scores. <Cite>REFNAME15</Cite> For the algorithm for the initial evaluation of patients with clinical symptoms of angina see figure 1
The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent complications including mortality based on risk scores. <Cite>REFNAME15</Cite> For the algorithm for the initial evaluation of patients with clinical symptoms of angina see Figure 1.
[[File:Figure_1_-_algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.png|thumb|right|400px|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]]


==Coronoary Angiography:==
==Coronoary Angiography==
Coronary angiography (CAG) can assist in the diagnosis and the selection of treatment options for stable angina pectoris. During CAG, the coronary anatomy is visualized including the presence of coronary luminal stenoses.  A catheter is inserted into the femoral artery or into the radial artery. The tip of the catheter is positioned at the beginning of the coronary arteries and contrast fluid is injected. The contrast is made visible by X ray and the images that are obtained are called angiograms.  
Coronary angiography (CAG) can assist in the diagnosis and the selection of treatment options for stable angina pectoris. During CAG, the coronary anatomy is visualized including the presence of coronary luminal stenoses.  A catheter is inserted into the femoral artery or into the radial artery. The tip of the catheter is positioned at the beginning of the coronary arteries and contrast fluid is injected. The contrast is made visible by X ray and the images that are obtained are called angiograms.  
If stenoses are visible, the operator will judge whether this stenosis is significant and eligible for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).  
If stenoses are visible, the operator will judge whether this stenosis is significant and eligible for percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).  
Line 176: Line 265:
#REFNAME18 pmid=3925741
#REFNAME18 pmid=3925741
#REFNAME19 pmid=9355934
#REFNAME19 pmid=9355934
#REFNAME20 pmid=12515758
#REFNAME20 pmid=23996286
</biblio>
</biblio>
467

edits

Navigation menu