Review Question - QID 106436

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Angina Introduction 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 QID: 106436 (M2.CV.15.62)

QID 106436 (Type "106436" in App Search)

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?

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

21%

19/92

A hypertensive patient who presents with an intracranial bleed and hemiplegia

4/92

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

15%

14/92

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

59%

54/92

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

0/92

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This patient is experiencing variant (Prinzmetal's) angina, which is caused by vasospasm. Raynaud's phenomenon (presenting as blue discoloration of the fingers) is the only condition listed which also is a result of vasospasm.

Unlike typical angina, which is caused by atherosclerosis, variant angina (also known as Prinzmetal's angina or, less commonly, cardiac syndrome X) is caused by vasospasm of the smooth muscle tissue in the coronary vessel walls. Variant angina attacks tend to occur cyclically and at night/rest. This is opposed to typical angina, which tends to occur with exertion and is relieved by rest.

As Achar et al. note, variant angina can be difficult to distinguish from typical angina on presentation. Clues pointing to variant angina include younger age, female sex, and chest pain that occurs suddenly at rest (see illustration A for risk stratification and illustration B for an algorithm for evaluating chest pain patients).

As Huckell et al. note, treatment for variant angina generally includes nitrates and calcium channel blockers. Beta blockers (e.g. propanolol) are contraindicated in variant spasm due to the possibility of unopposed coronary vasospasm.

Figure A demonstrates a 12 lead ECG showing anterolateral ST elevations.
Illustration A is a table showing risk stratification for acute coronary syndrome (ACS).
Illustration B is an algorithm for evaluating patients with chest pain.

Incorrect Answers:
Answer 1: A patient with crushing chest pain who shows a blockage in the LAD is experiencing a myocardial infarction, which is a result of thrombotic rupture of an atherosclerotic plaque.
Answer 2: A hypertensive patient who presents with an intracranial bleed and hemiplegia is experiencing a hemorrhagic stroke, which is not caused by vasospasm.
Answer 3: A smoker with diabetes who presents with pain in his calves while walking is experiencing claudication, which is a result of atherosclerosis.
Answer 5: This patient is experiencing a pulmonary embolism, which is caused by thrombosis and an embolic event.