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CHRONIC STABLE ANGINA
Chronic stable angina is a clinical syndrome characterized by squeezing, heaviness or pressure discomfort in the chest, neck, jaw, shoulder, back, or arms which is usually precipitated by exertion and/or emotional stress and relieved by rest and/or Nitroglycerin.
It is caused by myocardial ischemia that is commonly associated with narrowing of the coronary arteries.
Angina is stable when it is not a new symptom and when there is no deterioration in frequency, duration or severity of episodes.

Introduction

  • Clinical syndrome characterized by constricting discomfort in the chest, neck, jaw, shoulder, back, or arms which is precipitated by exertion and/or emotional stress and relieved by rest and/or Nitroglycerin
  • Can be attributed to myocardial ischemia of which atherosclerotic coronary artery disease is the most common cause
  • Angina is stable when it is not a new symptom and when there is no deterioration in frequency, duration, or severity of episodes

Signs and Symptoms

  • Quality of chest pain
    • Described as squeezing, grip-like, suffocating, and heavy pain but rarely sharp or stabbing and typically does not vary with position or respiration
    • Occasionally, the patient may demonstrate a Levine’s sign in which a clenched fist is placed over the precordium to describe the pain
    • Many patients do not describe angina as frank pain but as tightness, pressure, or discomfort
    • Other patients, particularly women and elderly, can manifest with atypical symptoms such as nausea, vomiting, midepigastric discomfort, or sharp (atypical) chest pain
  • Location of pain or discomfort
    • Usually substernal and pain can radiate to the neck, jaw, epigastrium, shoulders, back or arms
    • Pain above the mandible, localized to a small area over the left lateral chest wall, or below the epigastrium is rarely anginal
  • Duration of pain
    • Lasts for minutes usually not >20 minutes
  • Precipitating factors
    • Often precipitated by exertion, emotional stress, heavy meal, or cold weather
  • Alleviating factors
    • Typically relieved by rest
    • Sublingual Nitroglycerin also relieves angina within 30 seconds to several minutes

Risk Factors

Conditions that Exacerbate or Provoke Ischemia

Noncardiac Diseases
  • Hyperthyroidism
  • Hyperthermia
  • Anxiety
  • Anemia
  • Hyperviscosity
  • Leukemia
  • Hypertension
  • Sympathomimetic toxicity (eg cocaine toxicity)
  • Arteriovenous fistulae
  • Sickle cell disease
  • Polycythemia
  • Thrombocytosis
  • Hypergammaglobulinemia
  • Hypoxemia secondary to pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, interstitial pulmonary fibrosis
Cardiac Diseases  
  • Aortic stenosis
  • Dilated cardiomyopathy
  • Arrhythmias (eg supraventricular tachycardia, ventricular tachycardia)
  • Hypertrophic cardiomyopathy
  • Significant coronary obstruction
  • Microvascular disease
Rule Out Unstable Angina
  • Unstable angina is defined as angina of new onset, increases in frequency, intensity, or duration, or occurs at rest
  • Presence of unstable angina predicts a higher short-term risk of acute coronary event
  • Moderate- to high-risk patients should be promptly evaluated and treated in the emergency department because of higher risk of coronary artery plaque rupture and death
  • Low-risk patients are comparable to those patients with stable angina and their evaluation can be performed safely and expeditiously in an outpatient setting
  • See Acute Coronary Syndromes w/out Persistent ST-Segment Elevation Disease Management Chart for more details

Alternative Diagnosis

  • Non-ischemic chest pain may also be caused by neuralgia, myalgia, costochondritis, psychosomatic disorder, pericarditis, pleurisy, pneumothorax, pulmonary embolism, esophageal spasm, gastroesophageal reflux disease, peptic ulcer disease, gallstone disease, pancreatitis
Clinical Pre-test Probabilities (PTP)
  • Clinician’s pre-test estimates of disease along with the results of diagnostic tests to generate individualized post-test disease probabilities for a given patient
  • Influenced by the prevalence of the disease in the population studied, as well as clinical features including the presence of cardiovascular (CV) risk factors of an individual
  • Major determinants are age, gender and the nature of symptoms
  • According to the 2013 European Society of Cardiology (ESC) guidelines, PTP of CAD are as follows:
    • Low PTP <15%: Patients can be managed without further non-invasive stress testing but it is recommended to exclude other causes of chest pain (eg pulmonary, gastrointestinal, musculoskeletal)
    • Intermediate PTP ≥15-≤85%: An exercise ECG may be considered in patients with 15-65% PTP while a non-invasive imaging is preferred in those with 66-85% PTP
    • High PTP >85%: Patients can be assumed to have stable CAD and an invasive coronary angiography (ICA) may be considered for risk stratification
Assess for Ischemic Heart Disease (IHD) Risk Factors
  • Presence of IHD risk factors should be assessed
    • Eg Smoking, dyslipidemia, diabetes mellitus (DM), hypertension, obesity, metabolic syndrome, physical inactivity, and family history of premature IHD
  • History of cerebrovascular disease (CVD), peripheral artery disease (PAD), MI, or coronary revascularization also increases the likelihood of IHD
Risk Stratification
  • Risk refers to the risk of CV event (eg death)
    • Low risk has an annual mortality of <1%, intermediate risk 1-3% and high risk >3%
  • Uses clinical findings, resting ECG, response to stress testing, quantification of left ventricular function, and extent of coronary artery disease (CAD) to determine the level of risk 
  • Assists in deciding the appropriate therapy and determines prognosis of the disease
    • Low-risk patients are managed with risk factor reduction with or without anti-anginal therapy while intermediate to high-risk patients are referred to specialists for further evaluation and possible revascularization
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