Chronic stable angina history and symptoms: Difference between revisions

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(/* 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...)
 
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{{Chronic stable angina}}
{{Chronic stable angina}}


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


==Overview==
==Overview==
The name angina "pain" is somewhat of a misnomer in so far as patients often describe the sensation as a discomfort rather than a "pain". We will use the PQRST system to characterize that pain.
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'.


==P = provocation / palliation==
==History and Symptoms==
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.
===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.


Less common precipitants of anginal discomfort include emotional distress, a large meal, cold weather, cocaine, [[anemia]], and [[thyrotoxicosis]].
Stable angina can be classified basing upon features.
* Substernal [[chest pain]].
what were you doing when the pain started? What caused it? What makes it better? worse? What seems to trigger it? Stress? Position? Certain activities? Arguments? Does it seem to be getting better, or getting worse, or does it remain the same? What relieves it: changing diet? changing position? taking medications? being active? resting? What makes (the problem) worse?
* Pain provocated by exertion and/or emotional stress.
* Relieved with rest and/or [[nitroglycerin]].


==Q = quality / quantity==
Typical angina - All the three features.
What does it feel like? Is it sharp? Dull? Stabbing? Burning? Crushing? throbbing? nauseating? shooting? twisting? stretching? Other? (The person who is suffering the pain should describe the pain, rather than saying what they think you would like to hear.) How does it feel, look or sound? How much of it is there?
Atypical angina - two features.
Non-anginal chest pain - one feature.


==R = region / radiation==
===Quality/Quantity (Q)===
Where is the pain located? Does the pain radiate (i.e. spread to another location, eg. pain source is from thumb but pain spreads to elbow)? Where does it radiate? Is it all in one place? Does it go anywhere else? Did it start elsewhere and now localised to one spot? Does it feel like it travels/moves around?
* 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.


==S = severity scale==
===Region/Radiation (R)===
How severe is the pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever? Does it interfere with activities? How bad is it when it's at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?
* 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.


==T = timing==
===Severity Scale (S)===
When did the pain start, at what time? How long did it last? How often does it occur? Is it sudden or gradual? What were you doing when you first experienced or noticed it? How often do you experience it: hourly? daily? weekly? monthly? When do you usually experience it: daytime? night? in the early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?
* 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.


==Overview==
===Timing (T)===
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 the arms (often inner left arm), the shoulders, and the neck into the jaw.   The chest discomfort may be accompanied by breathlessness, sweating and [[nausea]] in some cases. The discomfort usually lasts for about 1 to 5 minutes, and it is relieved by rest or specific anti-angina medication. Chest discomfort lasting only a few seconds is usually 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.  Anginal ymptoms that are either progressively worsening (accelerated angina), occur at rest, or are of new-onset are classified as [[unstable angina]].
* 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.


==Type and quality of the pain==
===Associated Symptoms===
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.
*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.


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


==Radiation of the pain==
{| border="1" align="center" style="background:lightskyblue"
Typical locations for radiation of the pain are the arms (often inner left arm), shoulders, and neck into the jaw.
|-
|  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.  


==Severity of the pain==
*Ordinary physical activity does not cause [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]] that limit activity.
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.  
|
 
*Ordinary physical activity does not cause angina, such as walking, climbing stairs.
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.
*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>


==Relation to exertion==
==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>==
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.


==Duration of the pain==
===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>===
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.
'''Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain'''


==Precipitating factors==
{|class="wikitable"
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).
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


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.
|-
| 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>


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 relieves the symptoms, then it is unlikely that the symptoms are related to myocardial ischemia.
|-
| 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>
|}


==Relieving factors==
==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>==
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.


==ACC / AHA Guidelines- History and Physical examination Recommendations (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
{|class="wikitable"
{{cquote|
|-
===Class I===
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
'''1.''' In patients presenting with [[chest pain]], a detailed symptom history, focused physical examination, and directed [[Chronic stable angina risk stratification exercise testing|risk factor assessment]] should be performed. With this information, the clinician should estimate the [[Chronic stable angina assessing the pretest probability of coronary artery disease|probability]] of significant [[CAD]] (ie, low, intermediate, high). ''(Level of Evidence: B)''}}


==ESC Guidelines- Clinical Evaluation and ECG for Risk Stratification (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>==
|-
{{cquote|
| 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>
===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)''
| 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>
 
|}
'''2.''' Resting [[ECG]] in all patients. ''(Level of Evidence: B)''}}
 
==See Also==
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
 
==Sources==
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <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=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
 
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
 
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref>
 
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
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Latest revision as of 17:15, 28 October 2016

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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.


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