Chronic stable angina history and symptoms: Difference between revisions
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==Overview== | ==Overview== | ||
The name 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'. | ||
== | ==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. | * 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: | * Less common precipitants of anginal discomfort include: | ||
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* Substernal [[chest pain]]. | * Substernal [[chest pain]]. | ||
* Pain provocated by exertion and/or emotional stress. | * Pain provocated by exertion and/or emotional stress. | ||
* Relieved with rest and /or [[nitroglycerin]]. | * Relieved with rest and/or [[nitroglycerin]]. | ||
Typical angina - All the three features. | Typical angina - All the three features. | ||
| Line 28: | Line 29: | ||
Non-anginal chest pain - one feature. | 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: | * 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 | :* A sense of heaviness | ||
| Line 39: | Line 40: | ||
* The pain is not sharp or [[pleuritic]] in nature. This is in contrast [[pericarditis]] which is described in this way. | * 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. | * 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. | * 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. | * 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 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: | * The patient should be asked: | ||
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* 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. | * 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. | ||
==T = | ===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. | * 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. | * 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. | ||
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* In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy. | * In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy. | ||
==Associated Symptoms== | ===Associated Symptoms=== | ||
*There may be symptoms of systolic or diastolic left ventricular dysfunction that leads to shortness or breath or [[dyspnea]]. | *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 | *In some patients, chest discomfort is not present, and [[dyspnea]] is the anginal equivalent. | ||
<center> | <center> | ||
==Classifications of Functional | ==Classifications of Functional Capacity and Severity in Chronic Stable Angina== | ||
{| border="1" align="center" style="background:lightskyblue" | {| border="1" align="center" style="background:lightskyblue" | ||
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*Ordinary physical activity does not cause [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]] that limit activity. | *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. | *Angina occurs with strenuous, rapid or prolonged exertion at work or recreation. | ||
|- | |- | ||
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*Comfortable at rest, but ordinary physical activity results in [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]]. | *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: | *Angina occurs on: | ||
:*walking or climbing stairs rapidly, | :*walking or climbing stairs rapidly, | ||
| Line 99: | Line 100: | ||
*Comfortable at rest, but less than ordinary activity, such as walking 20–100 m, causes [[fatigue]], [[palpitation]], or [[dyspnea]]. | *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 | *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''' | | '''Class IV''' | ||
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*Usually self-confined to bed or a chair. | *Usually self-confined to bed or a chair. | ||
| | | | ||
* | *Inability to carry on any physical activity without any discomfort. | ||
*Angina occurs at rest. | *Angina occurs at rest. | ||
|}</center> | |}</center> | ||
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name=" | ==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>== | ||
=== | ===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''' | |||
{|class="wikitable" | {|class="wikitable" | ||
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|- | |- | ||
| bgcolor="LightGreen"| | | bgcolor="LightGreen"| | ||
<nowiki>"</nowiki>'''1.''' | <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> | |||
|- | |||
| 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>== | ==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>== | ||
{|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> | |||
|} | |||
==References== | ==References== | ||
Latest revision as of 17:15, 28 October 2016
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina history and symptoms On the Web | ||
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to Hospitals Treating Chronic stable angina history and symptoms | ||
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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:
- 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.
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?
- Both the New York Heart Association functional classification scheme (NYHA) and the Canadian Cardiovascular Society functional classification (CCS) can be used to quantify the severity of anginal pain.
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:
|
|
| Class II | Minimal limitation:
|
|
| Class III | Marked limitation:
|
|
| Class IV | Extreme limitation:
|
|
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
- ↑ 1.0 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.
- ↑ 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.