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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
  • Please see Acute Coronary Syndromes w/out Persistent ST-Segment Elevation disease management chart for further information
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