Chronic stable angina history and symptoms: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(/* ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT){{cite journal| author=Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al.| title=ACC/AHA/ACP-ASIM guidelines for the managemen...)
 
(53 intermediate revisions by 10 users not shown)
Line 1: Line 1:
{{SI}}
__NOTOC__
{{WikiDoc Cardiology Network Infobox}}
{{Chronic stable angina}}
{{CMG}}
 
'''Associate Editor-In-Chief:''' {{CZ}}
 
{{EJ}}
 
 
'''Click [[Chronic stable angina|''here'']] for the Chronic stable angina main page'''


{{CMG}}, '''Associate Editor-in-Chief:''' [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]


==Overview==
==Overview==
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina.  Angina is considered to be stable when it remains reasonably constant and predictable in terms of severity, presentation, character, precipitants, and response to therapy.  Symptoms as progressively worsening angina (accelerated angina), one or more episodes of angina at rest, or a new-onset angina classified as [[unstable angina]].
The name 'angina pain' can be thought of as a misnomer as patients often describes the sensation as discomfort rather than physical pain. The best method to characterize this discomfort/pain is through the 'PQRST system'.
 
==Type and quality of the pain==
 
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders.Pain or discomfort often described as tight, dull or heaviness at chest.  Some patients have difficulty to describing the discomfort or deny that their discomfort is a true pain at all.


==Location of the pain==
==History and Symptoms==
===Provocation/Palliation (P)===
* The most common cause of anginal pain is exertion.  Anginal discomfort is often relieved by rest or [[nitroglycerine]].  Usually relief from rest or nitroglycerine occurs in 2 to 3 minutes.
* Less common precipitants of anginal discomfort include:
:*Emotional distress
:* A large meal
:* Cold weather
:* Cocaine
:*[[Anemia]]
:*[[Thyrotoxicosis]]
* The discomfort is not precipitated by changes in position. This is in contrast to [[pericarditis]] which is relieved by sitting up or sitting forward.
* In following the patient with chronic stable angina, the duration and or distance of exertion required to provoke the angina should be recorded to monitor the response to therapy.


The pain is often retrosternal or left side of chest and can radiate to left arm, neck, jaw and back. The most frequent initial location of angina is in the central chest and the retrosternal area, but the left pectoral region, arms and hands, root of the neck, epigastrium, and even the right side of the chest may be initial sites. Quite frequently, the pain starts in one of the other areas and later on spreads to the central chest. Occasionally, patients may complain of only interscapular or left infrascapular back pain. Discomfort that is located below the umbilicus or above the mandible is unlikely to be angina.
Stable angina can be classified basing upon features.
* Substernal [[chest pain]].
* Pain provocated by exertion and/or emotional stress.
* Relieved with rest and/or [[nitroglycerin]].


==Radiation of the pain==
Typical angina - All the three features.
Atypical angina - two features.
Non-anginal chest pain - one feature.


Typical locations for radiation of the pain are the arms (often inner left arm), shoulders, and neck into the jaw.
===Quality/Quantity (Q)===
* The nature of the sensation is usually not described as a "pain" but rather as a discomfort.  It is often described as:
:* A sense of heaviness
:* Squeezing
:* Pressure
:* Choking
:* Strangling
:* Band like tightness
:* Or even as an "elephant sitting on my chest"
* The pain is not sharp or [[pleuritic]] in nature. This is in contrast [[pericarditis]] which is described in this way.


==Severity of the pain==
===Region/Radiation (R)===
* Typically the angina is located in the center of the chest or on the left side of the chest. 
* Less frequently the discomfort is predominantly in the [[epigastrum]], the shoulders, neck or jaw.
* In some patients, the pain may radiate to the inner aspect of the left arm, the neck or the jaw.


During the initial evaluation of patients with suspected or established angina, it is desirable to assess its severity as a guide to therapy.  A number of methods have been proposed to assess function impairment by history, based on the degree of physical activity that precipitates angina. The New York Heart Association (NYHA) functional classification has largely been replaced by the Canadian Cardiovascular Society (CCS) functional classifications or by classification systems based on the activity levels that can be related to the metabolic equivalents during treadmill exercise tests (A Specific Activity Scale developed by Goldman and colleagues and the angina score by Califf and colleagues). It should be noted that any functional classification is subject to variability in activity tolerance as perceived by patients and hence its reproducibility is variable.  
===Severity Scale (S)===
* The patient should be asked to rank their pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever.
* The patient should be asked:
:* Does the discomfort interferes with activities?
:* How bad the discomfort is when it is at its worst?
:* Does it force the patient to sit down, lie down, or slow down?
* Both the [[ New york heart association functional classification|New York Heart Association functional classification scheme]] (NYHA) and the [[Canadian Cardiovascular Society Classifications of Angina Pectoris|Canadian Cardiovascular Society functional classification]] (CCS) can be used to quantify the severity of anginal pain.


After an episode of severe, transient ischemia, the myocardium may be temporarily stunned, which means that it remains transiently dysfunctional after the ischemia has resolved. When a part of the myocardium is chronically hypoperfused, it may not show evidence of ischemia on the electrocardiogram but may still be dysfunctional or even akinetic. It is important to distinguish this reversible clinical entity (so called hibernating myocardium) from myocardium that is dysfunctional secondary to irreversible infarction, because hibernating myocardium may regain normal function when perfusion is restored.
===Timing (T)===
* Anginal discomfort usually lasts 1 to 5 minutes with a range from 1 minute to 30 minutes.  Pain that lasts seconds is usually not anginal pain.
* The pain is usually relieved in 2 to 3 minutes with rest or nitroglycerine. Anginal discomfort associated with emotional distress is usually relieved more slowly.
* Angina that occurs at night ([[Nocturnal angina pectoris|nocturnal angina]]) is characteristic of [[Coronary Vasospasm|coronary spasm]].
* In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy.


==Relation to exertion==
===Associated Symptoms===
*There may be symptoms of systolic or diastolic left ventricular dysfunction that leads to shortness or breath or [[dyspnea]].
Angina is often brought on with exertion or emotional stress and in majority of cases eased with rest. Exertion induced angina ([[exertional angina]]), which is the most common clinical presentation of patients with stable angina, is precipitated by an increase in myocardial oxygen demand above myocardial oxygen supply. In some patients, however, myocardial ischemia is partially or totally secondary to a spontaneous reduction in coronary blood flow.
*In some patients, chest discomfort is not present, and [[dyspnea]] is the anginal equivalent.


==Duration of the pain==
<center>
==Classifications of Functional Capacity and Severity in Chronic Stable Angina==


Typically angina pectoris symptoms last up to several minutes after exertion or emotional stress has stopped. The duration of angina pectoris is variable but it usually lasts 2 to 5 minutes. It is uncommon for the episodes of stable angina pectoris to be either very brief (<60 sec), or prolonged (>30 min).  Anginal pain provoked by emotion may be relieved more slowly than that provoked by physical exercise.
{| border="1" align="center" style="background:lightskyblue"
|-
|  bgcolor="CornFlowerBlue" |'''Class'''
|  bgcolor="CornFlowerBlue" |'''[[NYHA classification|New York Heart Association Classification]]'''
|  bgcolor="CornFlowerBlue" |'''[[CCS classification|Canadian Cardiovascular Society Classification]]'''
|-
| '''Class I'''
|'''No limitation:'''
*Heart disease exists with no symptoms or limitation of physical activity.  


==Precipitating factors==
*Ordinary physical activity does not cause [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]] that limit activity.
|
*Ordinary physical activity does not cause angina, such as walking, climbing stairs.
*Angina occurs with strenuous, rapid or prolonged exertion at work or recreation.
|-
| '''Class II'''
| '''Minimal limitation:'''
*There is slight limitation of physical activity.
*Comfortable at rest, but ordinary physical activity results in [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]].
|
*Slightly limited ordinary physical activities.
*Angina occurs on:
:*walking or climbing stairs rapidly,
:*walking uphill, walking or stair climbing after meals, or in cold, or in wind, or
:*under emotional stress, or
:*only during the few hours after awakening.
*Walking more than two blocks on the same level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
|-
| '''Class III'''
| '''Marked limitation:'''
*Patients have marked limitation of physical activity.
*Comfortable at rest, but less than ordinary activity, such as walking 20–100 m, causes [[fatigue]], [[palpitation]], or [[dyspnea]].
|
*Marked limitations of ordinary physical activity.
*Angina occurs on walking one to two blocks (equivalent to 100-200m) on the same level and climbing one flight of stairs at a normal pace under normal conditions.
|-
| '''Class IV'''
| '''Extreme limitation:'''
*Severe limitation; unable to carry out any physical activity without discomfort.
*[[chronic stable angina|Angina]] and/or symptoms of cardiac insufficiency may be present at rest.
*If any physical activity is undertaken, discomfort is increased.
*Usually self-confined to bed or a chair.
|
*Inability to carry on any physical activity without any discomfort.
*Angina occurs at rest.
|}</center>


Precipitating factors include emotions (anger, excitation, fear and frustration), cold weather, a heavy meal and cocaine use. Exertional angina or classic angina is characteristically induced by physical activity and is often precipitated more easily in cold weather or after eating a heavy meal (fatty and/or spicy meal).  
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==


Some patients, experience angina pectoris more frequently in the early morning than during the remainder of the day despite less or no physical activity at this time. Exercising the upper extremities above the head precipitates angina more readily than exercising the lower extremities.
===Clinical Evaluation of Patients With Chest Pain (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>===
'''Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain'''


In some patients dyspnea may reflect myocardial ischemia and left ventricular dysfunction and may be termed an "anginal equivalent". Both ischemic cardiac discomfort and cardiac dyspnea are worse during physical activity than at rest, and if activity releives the symptoms, then it is unlikely that the symptoms are related to myocardial ischemia.
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


==Relieving factors==
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional
testing.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>


The impact of rest, discontinuation of the activity and nitroglycerin administration should be evaluated.  The relief of angina usually occurs within several minutes after cessation of exertion (it may last up to 10 minutes or even longer after very strenuous exercise). Prompt relief is also achieved with administration of sublingual nitroglycerin. The hemodynamic effects of sublingual nitroglycerin usually begin within a minute, and the stable angina is generally relieved within 2 or 3 minutes. Chest discomfort that is instantaneously relieved by nitroglycerin is less likely to be angina pectoris.
|-
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''2.''' Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as
being at high, moderate, or low risk.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>
|}


==ESC Guidelines- Clinical Evaluation (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==


[[{{PAGENAME}}#Overview|''Return to top'']]
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]


|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Detailed clinical history and [[physical examination]] including [[BMI]] and/or waist circumference in all patients, also including a full description of symptoms, quantification of functional impairment, past medical history, and [[Coronary risk profile (patient information)|cardiovascular risk profile]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina electrocardiography|Resting ECG]] in all patients. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


{{Circulatory system pathology}}
==References==
{{SIB}}
{{reflist|2}}
[[Category:Cardiology]]


{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
[[Category:Disease]]
[[Category:Ischemic heart diseases]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Latest revision as of 17:15, 28 October 2016

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

Secondary Prevention

Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

Landmark Trials

Case Studies

Case #1

Chronic stable angina history and symptoms On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic stable angina history and symptoms

CDC onChronic stable angina history and symptoms

Chronic stable angina history and symptoms in the news

Blogs on Chronic stable angina history and symptoms

to Hospitals Treating Chronic stable angina history and symptoms

Risk calculators and risk factors for Chronic stable angina history and symptoms

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

The name 'angina pain' can be thought of as a misnomer as patients often describes the sensation as discomfort rather than physical pain. The best method to characterize this discomfort/pain is through the 'PQRST system'.

History and Symptoms

Provocation/Palliation (P)

  • The most common cause of anginal pain is exertion. Anginal discomfort is often relieved by rest or nitroglycerine. Usually relief from rest or nitroglycerine occurs in 2 to 3 minutes.
  • Less common precipitants of anginal discomfort include:
  • The discomfort is not precipitated by changes in position. This is in contrast to pericarditis which is relieved by sitting up or sitting forward.
  • In following the patient with chronic stable angina, the duration and or distance of exertion required to provoke the angina should be recorded to monitor the response to therapy.

Stable angina can be classified basing upon features.

  • Substernal chest pain.
  • Pain provocated by exertion and/or emotional stress.
  • Relieved with rest and/or nitroglycerin.

Typical angina - All the three features. Atypical angina - two features. Non-anginal chest pain - one feature.

Quality/Quantity (Q)

  • The nature of the sensation is usually not described as a "pain" but rather as a discomfort. It is often described as:
  • A sense of heaviness
  • Squeezing
  • Pressure
  • Choking
  • Strangling
  • Band like tightness
  • Or even as an "elephant sitting on my chest"
  • The pain is not sharp or pleuritic in nature. This is in contrast pericarditis which is described in this way.

Region/Radiation (R)

  • Typically the angina is located in the center of the chest or on the left side of the chest.
  • Less frequently the discomfort is predominantly in the epigastrum, the shoulders, neck or jaw.
  • In some patients, the pain may radiate to the inner aspect of the left arm, the neck or the jaw.

Severity Scale (S)

  • The patient should be asked to rank their pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever.
  • The patient should be asked:
  • Does the discomfort interferes with activities?
  • How bad the discomfort is when it is at its worst?
  • Does it force the patient to sit down, lie down, or slow down?

Timing (T)

  • Anginal discomfort usually lasts 1 to 5 minutes with a range from 1 minute to 30 minutes. Pain that lasts seconds is usually not anginal pain.
  • The pain is usually relieved in 2 to 3 minutes with rest or nitroglycerine. Anginal discomfort associated with emotional distress is usually relieved more slowly.
  • Angina that occurs at night (nocturnal angina) is characteristic of coronary spasm.
  • In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy.

Associated Symptoms

  • There may be symptoms of systolic or diastolic left ventricular dysfunction that leads to shortness or breath or dyspnea.
  • In some patients, chest discomfort is not present, and dyspnea is the anginal equivalent.

Classifications of Functional Capacity and Severity in Chronic Stable Angina

Class New York Heart Association Classification Canadian Cardiovascular Society Classification
Class I No limitation:
  • Heart disease exists with no symptoms or limitation of physical activity.
  • Ordinary physical activity does not cause angina, such as walking, climbing stairs.
  • Angina occurs with strenuous, rapid or prolonged exertion at work or recreation.
Class II Minimal limitation:
  • There is slight limitation of physical activity.
  • Slightly limited ordinary physical activities.
  • Angina occurs on:
  • walking or climbing stairs rapidly,
  • walking uphill, walking or stair climbing after meals, or in cold, or in wind, or
  • under emotional stress, or
  • only during the few hours after awakening.
  • Walking more than two blocks on the same level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
Class III Marked limitation:
  • Patients have marked limitation of physical activity.
  • Comfortable at rest, but less than ordinary activity, such as walking 20–100 m, causes fatigue, palpitation, or dyspnea.
  • Marked limitations of ordinary physical activity.
  • Angina occurs on walking one to two blocks (equivalent to 100-200m) on the same level and climbing one flight of stairs at a normal pace under normal conditions.
Class IV Extreme limitation:
  • Severe limitation; unable to carry out any physical activity without discomfort.
  • Angina and/or symptoms of cardiac insufficiency may be present at rest.
  • If any physical activity is undertaken, discomfort is increased.
  • Usually self-confined to bed or a chair.
  • Inability to carry on any physical activity without any discomfort.
  • Angina occurs at rest.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1]

Clinical Evaluation of Patients With Chest Pain (DO NOT EDIT)[1]

Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain

Class I

"1. Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional testing.(Level of Evidence:C)"

"2. Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as being at high, moderate, or low risk.(Level of Evidence:C)"

ESC Guidelines- Clinical Evaluation (DO NOT EDIT)[2]

Class I
"1. Detailed clinical history and physical examination including BMI and/or waist circumference in all patients, also including a full description of symptoms, quantification of functional impairment, past medical history, and cardiovascular risk profile. (Level of Evidence: B)"
"2. Resting ECG in all patients. (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  2. ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.


Template:WikiDoc Sources

Retrieved from "https://www.wikidoc.org/index.php?title=Chronic_stable_angina_history_and_symptoms&oldid=1264696"