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Snapshot
  • A 70-year-old man presents to his primary care physician complaining of recurrent, intermittent, sudden-onset chest pain and shortness of breath. He reports that while he often tires easily climbing the stairs, he recently has been experiencing episodes of chest pain even while watching TV. He would not have come today if his wife had not made him.
Introduction
  • Caused by coronary artery disease 
  • Presents with chest pain and/or tightness diagnosed as
    • stable angina 
      • predictable
        • presenting with consistent amount of exertion
      • the patient can achieve relief with rest or nitroglycerin
      • indicative of a stable, flow-limiting plaque
    • unstable angina
      • defined as any new angina or rapidly worsening stable angina
      •  unpredictable
        • often presenting during periods of inactivity
          • such as sitting and watching television
      • limited improvement with nitroglycerin
      • and usually recurs soon afterward
      • indicative of a ruptured plaque with subsequent clot-formation in the vessel
Presentation
  • Symptoms
    • classic triad of stable angina includes
      • chest pain
      • precipitated by exertion
      • and relieved by rest or nitrates
    • radiates to arms, jaw, and/or neck
    • may include diaphoresis, nausea, and lightheadedness
    • classic symptoms do not always present in the elderly, women, and diabetics
  • Physical Exam
    • is generally unremarkable in these patients
    • might identify bruits and hypertension on evaluation
Evaluation
  • EKG may demonstrate
    • ST-segment depression
    • ST-segment elevation
    • T wave inversion
    • Q waves
  • Labs
    • May have elevated cardiac enzymes (troponin, CK, CK-MB)
  • Evaluate risks via exercise stress test or catheterization
...Differential
  • MI, PE, angina, variant/Prinzmetal's angina, thoracic aortic aneurysm, esophageal rupture, pancreatitis, pseudocyst, neoplasms, orthopedic causes of back pain, appendicitis, and gallbladder disease, GERD 
Treatment
  • Treat acute symptoms
    • morphine
    • oxygen
    • nitroglycerin
    • aspirin
    • ACEIs
    • and beta-blockers
  • Admit to CCU to rule-out MI
    • 3 sets of cardiac enzymes (or 2 sets spaced 12 hours apart
  • Heparinization and angiography/angioplasty
    • in patients with EKG changes or worsening symptoms
  • Calcium channel blocker (nifedipine)
    • for chronic management of unstable angina
  • CABG indicated in cases of 
    • failure of medical therapy
    • three-vessel disease
    • or two-vessel disease in diabetics
  • Discharge home
    • if pain decreases
    • negative EKG and enzymes
    • focus on risk factor reduction (i.e. diet, exercise, BP control, cholesterol control, smoking)
Prognosis, Prevention, and Complications
  •  See Ischemic Heart Disease for prevention and complications
 

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