Snap Shot
  • A 49-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 stairs, recently he has been experiencing episodes of chest pain even while watching TV. He would not have come today, if his wife had not made him.
  • Causes
    • metabolic demand by the heart is not met as a result of several possible causes
      • coronary artery disease (↓ blood flow)
      • aortic stenosis with left ventricular hypertrophy (↓ cardiac output)
      • hypertrophic cardiomyopathy (↓ cardiac output)
  • Types
    • 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
      • example of subendocardial ischemia
    • 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 
      • example of subendocardial ischemia
    • Prinzmetal's angina 
      • intermittent coronary vasospasm
        • PrinZmetal = vasosPaZm
      • caused by thromboxane A2 or endothelin
      • Relief with rest, nitroglycerin, or calcium-channel blocker
  • 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
    • unstable and Prinzmetal's anginas occur at rest
  • Physical Exam
    • generally unremarkable
    • might identify bruits and hypertension
  • EKG may demonstrate
    • ST-segment depression
      • due to sub-endocardial ischemia
      • seen in stable, unstable anginas
    • ST-segment elevation 
      • due to transmural ischemia
      • Prinzmetal's
    • T wave inversion
    • Q waves
  • May have elevated cardiac enzymes (troponin, CK, CK-MB)
  • Evaluate risks via exercise stress test or catheterization

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