Updated: 2/6/2020

Angina

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Snapshot
  • A 70-year-old man presents to his primary care physician with recurrent, intermittent, sudden-onset chest pain and shortness of breath. He reports that he often tires easily climbing the stairs. Initially, he experienced chest pain with activity, but now it occurs throughout the day. Medical history is significant for hypertension and type II diabetes. An electrocardiogram demonstrates mild ST-segment depressions in V1-V2. Cardiac troponins are not elevated. (Unstable angina)
Introduction
  • Clinical definition
    • substernal chest discomfort secondary to myocardial ischemia; however, myocyte necrosis is not present
      • note that patient will likely report discomfort rather than pain
  • Epidemiology
    • risk factors
      • smoking
      • atherosclerosis
      • poor dietary habits
  • Pathogenesis
    • background
      • myocardial ischemia occurs when the heart's demand for oxygen exceeds oxygen supply
        • factors that increase the heart's demand for oxygen include
          • heart rate
          • contractility
          • systolic blood pressure
          • myocardial wall tension/stress
        • determinants of oxygen supply include
          • oxygen carrying capacity
          • unloading of oxygen from hemoglobin
          • coronary artery blood flow
            • coronary steal
              • when a vasodilatory agent causes worsening chest pain by shunting blood away from ischemic myocardium 
    • pathology
      • myocardial ischemia leads to acidosis, a ↓ ATP supply, and the release of chemical substances (e.g., adenosine)
        • sympathetic sensory neurons become activated and result in the perception of pain in a dermatomal distribution
          • e.g., chest, neck, jaw, and down the left (most commonly) arm
          • geriatric or diabetic patients may not experience chest discomfort or pain due to impaired sensory nerve conduction (e.g., diabetic neuropathy) or may present with atypical symptoms (such as GI pain, nausea, and vomiting)
            • obtain an ECG in all patients who could be presenting with atypical symptoms 
  • General work-up
    • Initial
      • EKG 
      • Cardiac biomarkers: troponin, CK, and/or CK-MB
      • CXR
    • Cardiac catheterization for definitive diagnosis for high-risk patients
      • locate and assess severity of the lesion(s) +/- treatment (i.e., stent)
    • Stress-testing
      • to evaluate simultaneously with EKG, echo, and radionuclide perfusion studies
      • for patients with intermediate-risk (i.e., chest pain that develops with exertion, but is relieved with rest or nitroglycerin, CAD risk factors)
      • all antianginal medications (beta-blockers, nitrates, calcium channel blockers) should be held for 48 hours before a stress test
      • for pharmacological stress tests using adenosine or regadenoson, use of dipyridamole should be held for 48 hours and intake of caffeine held for 12 hours to minimize false negative findings of ischemia
    • Low risk patients with negative work-up can be discharged with reassurance 
      • young (<50 years of age), female, active, non-smoker, chest pain not associated with exertion
 
Types of Angina
Types Pathology
Clinical Presentation Comments
Stable angina 
  • Typically secondary to atherosclerosis
    • this impairs coronary perfusion in the setting of increased cardiac demand (e.g., exertion)
  • Chest pain that develops with exertion but relieves with rest or nitroglycerin
  • Electrocardiogram
    • may demonstrate ST segment depressions
Unstable angina
  • Incomplete coronary artery occlusion by a thrombus
    • indicative of a ruptured plaque with subsequent clot formation
  • Chest pain that persists whether with decreasing physical activity or rest 
  • Electrocardiogram
    • may demonstrate ST segment depressions or T wave inversions
Prinzmetal angina
  • Coronary artery spasms 
  • Chest discomfort unrelated to physical activity and is episodic
  • Triggers
    • cocaine
    • alcohol
    • triptans
  • Electrocardiogram
    • appears similar to a STEMI
    • may demonstrate ST segment elevations with reciprocal ST depressions
  • Treatment
    • calcium channel blockers
    • smoking cessation
    • nitrates
 
 

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Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.15.4672) A 72-year-old man with a history of chronic kidney disease presents to his primary care physician complaining of recurrent chest pain with activity. The patient used to have chest pain when he mowed his lawn. Now he gets chest pain whenever he walks short distances such as to get his mail. The pain resolves on its own when the patient sits and rests. His temperature is 98.2°F (36.8°C), blood pressure is 157/98 mm Hg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man who is in no distress. An initial ECG is unchanged from a previous ECG. The patient's first troponin is 0.06 ng/mL which is unchanged from previous troponins. Which of the following is the most likely diagnosis? Review Topic | Tested Concept

QID: 107180
1

NSTEMI

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Stable angina

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STEMI

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Unstable angina

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(0/0)

5

Variant angina

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(0/0)

L 3 E

Select Answer to see Preferred Response

(M2.CV.15.62) A 50-year-old woman with no significant medical history comes to your office complaining of "chest pain attacks." She says that these attacks tend to occur in the middle of the night or early morning, and only last 15-20 minutes. She describes the pain as sharp and substernal. You perform an electrocardiogram (EKG), which is unremarkable. Suspecting the diagnosis, you perform another EKG following administration of ergonovine, and observed transiently the following (Figure A). Which of the following conditions has a pathophysiology most similar to this patient's condition? Review Topic | Tested Concept

QID: 106436
FIGURES:
1

A patient with crushing chest pain who has an blockage in the left anterior descending (LAD) artery

21%

(18/84)

2

A hypertensive patient who presents with an intracranial bleed and hemiplegia

5%

(4/84)

3

A smoker with diabetes who presents with pain in his calves while walking

14%

(12/84)

4

A woman who complains of blue discoloration of her fingers when she walks outside in the winter

58%

(49/84)

5

A pregnant woman with a history of deep vein thrombosis who presents with shortness of breath and filling defects on CT angiography

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(0/84)

L 1 C

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