Evaluation of Chest Pain Focusing on Angina

Evaluation of Chest Pain Focusing on Angina

Important differential diagnoses of chest pain in an adult are:

Angina pectoris/myocardial infarction
Pericarditis
Aortic dissection
Pleurisy
Pneumothorax
Esophageal spasm/oesophagitis
Musculoskeletal/Costochondritis
Bornholm disease also known as Devil’s grip and epidemic pleurodynia

Acute coronary syndromes

Unstable angina

Angina at rest or lowering of threshold for pre-existing effort angina

NSTEMI (Non ST elevation myocardial infarction)

Anginal pain at rest, associated with ECG changes, typically ST segment depression and T wave inversion, if troponin is elevated, it qualifies for the diagnosis of NSTEMI

STEMI (ST elevation myocardial infarction)

Similar to NSTEMI, but with ST elevation on ECG, qualifies for primary angioplasty if feasible or thrombolytic therapy if not contraindicated.

Evaluate the nature of the symptoms, history of ischaemic heart disease – patients with prior history are more at risk of further episodes. Male gender, advancing age and family history of coronary artery disease are non-modifiable risk factors. Traditional cardiac risk factors are diabetes mellitus, hypertension, dyslipidaemia and smoking. Lifestyle factors like obesity, lack of exercise, poor diet and stress also contribute.

Evaluation of angina

History is the key
Usually there are no physical signs
ECG  may be normal most of the time
Blood pressure and BMI have to be recorded
Look for murmurs, especially an ejection systolic murmur of aortic stenosis which can cause effort angina
Evidence of peripheral vascular disease and carotid bruits have to be sought as these would suggest more severe associated coronary artery disease and have implications in management

Types of angina

Chronic stable angina
Nocturnal angina
Unstable angina
Variant angina or Prinzmetal’s angina
Cardiac syndrome X – Microvascular angina

Unstable Angina

Unstable angina is defined as recurrent episodes of angina on minimal effort or at rest. It may be the initial presentation of coronary artery disease or it may represent the abrupt deterioration of a previously stable angina.
Crescendo angina, preinfarction angina and intermediate chest pain syndrome are also part of the spectrum of unstable angina. Angina is provoked more easily and persists for longer than stable angina. It may fail to respond to therapy. Pain is often associated with reversible ST segment depression on the ECG. Unless vigorously treated, up to 30% of patients may progress to myocardial infarction or death within 3 months

Prinzmetal’s/Variant Angina

Prinzmetal’s angina is caused by focal spasm of angiographically normal coronary arteries. In about two thirds of patients there is also associated atherosclerotic coronary artery obstruction. In cases where there is atherosclerotic obstruction the vasospasm occurs near the stenotic lesion. The chest pain may occur at rest or wake the patient from sleep. Variant angina may be accompanied by dyspnoea and/or palpitations

Cardiac Syndrome  X

Cardiac Syndrome  X is different from the metabolic Syndrome  X. Symptoms and signs of angina occur in spite of angiographically normal coronary arteries. They have evidence of ischemia in the form of a positive exercise test. Syndrome X may be due to microvascular disease and is sometimes called microvascular angina.