Chest Pain / Angina Pectoris: Difference between revisions

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===History===
===History===
Patients often experience angina pectoris as if a elephant stands on their chest. Because the heart itself has very few nerves the pain can be sensible elsewhere in the upper body, mainly arms, jaw and/or back.<cite>Foreman</cite> Some patients only complain about stomach ache so the presentation can be very a specific.<cite>Canto</cite> <cite>Pope</cite>
Patients often experience angina pectoris as if a elephant stands on their chest. Because the heart itself has very few nerves the pain can be sensible elsewhere in the upper body, mainly arms, jaw and/or back.<cite>Foreman</cite> Some patients only complain about stomach ache so the presentation can be very a specific.<cite>Canto</cite>,<cite>Pope</cite>


Angina pectoris however has some characteristics that can help to differentiate between other causes of (chest) pain. Angina pectoris is gradual in onset and offset, with the intensity increasing and decreasing over several minutes. The pain is constant and does not change with respiration or position. If patients had angina pectoris before they will recognize the pain immediately.<cite>Constant</cite>   
Angina pectoris however has some characteristics that can help to differentiate between other causes of (chest) pain. Angina pectoris is gradual in onset and offset, with the intensity increasing and decreasing over several minutes. The pain is constant and does not change with respiration or position. If patients had angina pectoris before they will recognize the pain immediately.<cite>Constant</cite>   
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===ECG===
===ECG===
[[File:TBC00003.jpg|200px|thumb|right|]]
[[File:TBC00003.jpg|200px|thumb|right|]]


The electrocardiogram (ECG) is an easy and important tool to differentiate between myocardial ischemia and infarction. Patients with unstable angina pectoris will show abnormalities on the ECG at rest, in particular ST depression.
The electrocardiogram (ECG) is an easy and important tool to differentiate between myocardial ischemia and infarction. Patients with unstable angina pectoris will show abnormalities on the ECG at rest, in particular ST depression.
Patients with stable angina pectoris are likely to have a completely normal ECG at rest, exercise ECG testing will be necessary to show any abnormalities. During exercise ECG testing an ECG is made during cycling on a home trainer or walking on a treadmill. While exercising the oxygen demand of the heart increases, if the narrowed coronary arteries are unable to supply enough oxygenated blood, the patient develops pain on the chest and the ECG will show abnormalities.<cite>Fox</cite>
Patients with stable angina pectoris are likely to have a completely normal ECG at rest, exercise ECG testing will be necessary to show any abnormalities.<cite>Ref1</cite> During exercise ECG testing an ECG is made during cycling on a home trainer or walking on a treadmill. While exercising the oxygen demand of the heart increases, if the narrowed coronary arteries are unable to supply enough oxygenated blood, the patient develops pain on the chest and the ECG will show abnormalities.<cite>Fox</cite>


===Additional Research===
===Additional Research===
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The findings on stress testing can be used to determine the choice between medical therapy and revascularization in patients with stable angina. Coronary angiography is recommended based upon symptoms, left ventricular function, and estimated risk by stress testing.<cite>Fraker</cite>
The findings on stress testing can be used to determine the choice between medical therapy and revascularization in patients with stable angina. Coronary angiography is recommended based upon symptoms, left ventricular function, and estimated risk by stress testing.<cite>Fraker</cite>


===Cardiac Markers===
'''Table 1'''
In addition to an ECG it is common to take blood samples and run the blood for elevated cardiac markers. Elevated CK MB and Troponin I indicate ischemia. It can however take 4-8 hours, after the symptoms started, before CK MB is elevated. The same applies to Troponin I, the advise is to repeat the measurements after 4-6 hours. A pitfall concerning elevated Troponin I can be patients with renal failure or pulmonary embolism.  
 
Positive cardiac markers indicate non ST elevation MI (NSTEMI), negative cardiac markers indicate unstable angina pectoris.
==Coronary Angiography==
In patients with unstable angina pectoris early coronary angiography possibly followed by revascularization is usually performed within 4 to 24 hours of admission in the hospital. In most clinical trials this strategy has shown a reduction in the incidence of death or nonfatal myocardial infraction.<cite>Anderson2</cite>
 
A CAG is an X ray examination of the coronary arteries, 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. Contrast is visible by X ray and the images that are obtained are called angiograms.
 
On an angiogram stenoses will be visible, if the stenosis is significant coronary intervention will take place. Ideally this happens immediately following the CAG but not all hospitals that are entitled to carry out CAG are qualified to perform percutaneous coronary intervention (PCI).  


==Treatment==
==Treatment==
===Medication===
===Medication===
In patients with stable angina pectoris with little or no symptoms and no abnormalities found during additional research, treatment focuses on preventing angina pectoris and reducing the risk of a heart attack to a minimum. Therefore medication, all aimed to keep the workload of the heart as low as possible, will be necessary.
In patients with stable angina pectoris percutaneous coronary intervention does not offer any benefit in terms of death, myocardial infarction, or the need for subsequent revascularization compared with conservative medical treatment.<cite>Katritsis</cite>
β blockers lower heart rate and blood pressure, this decreases the oxygen demand of the heart.
Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood. Anticoagulants reduce the risk of development of a thrombus in the coronary arteries.
Statins to lower cholesterol levels.  


Apart from starting medication the patient needs to minimize any present risk factors like smoking, overweight and drinking alcohol. See chronic coronary diseases.  
Initial treatment of stable angina pectoris therefore focuses on medication to keep the workload of the heart as low as possible. β blockers lower heart rate and blood pressure, this decreases the oxygen demand of the heart.<cite>Garcia</cite> Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood.<cite>Abrams2</cite> Anticoagulants (aspirin) to reduce the risk of development of a thrombus in the coronary arteries.<cite>Hennekens</cite>


===Coronary Angiography===
Apart from starting medication the patient needs to minimize any present risk factors like smoking, overweight and drinking alcohol. ''See chronic coronary diseases''.
Coronary angiography (CAG) is an X ray examination of the coronary arteries, 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. Contrast is visible by X ray and the images that are obtained are called angiograms.
On an angiogram stenoses will be visible, if the stenosis is significant coronary intervention will take place. Ideally this happens immediately following the CAG but not all hospitals that are entitled to carry out CAG are qualified to perform percutaneous coronary intervention (PCI).


===Percutaneous Coronary Intervention===
==Percutaneous Coronary Intervention==
The procedure of PCI is similar to a CAG, except this time a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent that the effect of the balloon is only temporarily a stent is often positioned at the site of the stenosis.  
The procedure of PCI is similar to a CAG, except this time a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent that the effect of the balloon is only temporarily a stent is often positioned at the site of the stenosis.  


===Coronary Artery Bypass Graft===
==Coronary Artery Bypass Graft==  
When the coronary arteries contain too many or too severe stenoses for PCI a coronary artery bypass graft (CABG) is indicated. Especially when the stenoses are located proximally of the three major coronary arteries, causing occlusion of many ramifications and high risk of severe myocardial damage.
There are circumstances in which CABG should be performed.  
 
CABG does not eliminate the stenosis like PCI does. Using the internal thoracic arteries or the saphenous veins from the legs a bypass is made around the stenosis. The bypass originates from the aorta and terminates directly after the stenosis. Thereby restoring the blood supply to the ramifications.
 
A bypass can be single or multiple, multiple meaning that there are several coronary arteries bypassed using the same bypass.


{| class="wikitable" border="1" style="width: 700px"
{| class="wikitable" border="1" style="width: 700px"
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|-
|-
| colspan="2" | Class I - There is evidence and/or general agreement that CABG should be performed in patients with STEMI in the following settings.
| colspan="2" | Class I - There is evidence and/or general agreement that CABG should be performed in patients with STEMI in the following settings.
|}
CABG does not eliminate the stenosis like PCI does. Using the internal thoracic arteries or the saphenous veins from the legs a bypass is made around the stenosis. The bypass originates from the aorta and terminates directly after the stenosis. Thereby restoring the blood supply to the ramifications.
=Myocardial Infarction=
In 2006 425.425 people died from a heart attack, 1.255.000 new and recurrent coronary attacks took place, about 34% died, 17.600.000 victims of angina, heart attack and other forms of coronary heart disease are still living.
These numbers only account for the United States.
==Pathofysiology==
A heart attack or myocardial infarction (MI) is an acute presentation of a process that has been going on much longer. The process responsible is atherosclerosis. Atherosclerosis is a chronic disease of the arteries in which artery walls thicken by deposition of fatty materials such as cholesterol. The result over decades are plaques, which can narrow the lumen of the arteries significantly and progressively causing symptoms as angina pectoris. Plaques can also suddenly rupture, trigger a cascade which results in a thrombus and thereby cause myocardial infarction.<cite>Davies3</cite>
==History==
Classic presentation of a myocardial infarction is acute chest pain which lasts longer than a few minutes. PMID 16304077 The pain does not decrease at rest and is only temporarily relieved with nitroglycerin. Common accompanying symptoms are radiating pain to shoulder, arm, back and/or jaw. PMID 10099685 Shortness of breath can occur, as well as sweating, fainting, nausea and vomiting, so called vegetative symptoms. Some patients not really complain about chest pain but more about abdominal pain so as with angina pectoris the presentation can be very a specific. PMID 10866870, PMID 10751787
It is important to complete the history with information about past history (prior history of ischemic events or vascular disease), risk factors for cardiovascular disease (o.a. smoking, hypertension, hyperlipidemia, obesity) and family history (direct family with myocardial infarction and/or sudden cardiac death).
Signs of heart failure such as orthopnea (not able to sleep without a pillow), progressive dyspnoea and oedematous ankles are indicative for the extent of the problem. PMID 15289388
A suspected myocardial infarction should be rapidly evaluated to initiate appropriate therapy.
==Physical Examination==
On physical examination evidence of systemic hypoperfusion can be found such as hypotension, tachycardia, impaired cognition, pale and ashen skin. PMID 15289388
If during auscultation pulmonary crackles are heard and pitting oedema of the ankles is seen heart failure is complicating the myocardial infarction.
History and physical examination are helpful to determine myocardial infarction as diagnosis and to exclude other causes of chest pain, such as angina pectoris, aorta dissection, arrhythmias, pulmonary embolism, pneumonia, heartburn, hyperventilation or musculoskeletal problems. PMID 15289388


|}


==References==
==References==
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#Constant pmid=6831781
#Constant pmid=6831781
#Anderson pmid=17692738
#Anderson pmid=17692738
#Anderson2 pmid=17692738
#Abrams pmid=3925741
#Abrams pmid=3925741
#Abrams2 pmid=3925741
#Henrikson pmid=14678917
#Henrikson pmid=14678917
#Antman pmid=15289388
#Antman pmid=15289388
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#Kwong pmid=12566362
#Kwong pmid=12566362
#Fraker pmid=18061078
#Fraker pmid=18061078
#Katritsis pmid=15927966
#Garcia pmid=16735367
#Hennekens pmid=9355934
#Davies3 pmid=11084798
#Ref1 pmid=8375424
</biblio>
</biblio>
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