Chronic stable angina history and symptoms
P = provocation / palliation : 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?
Q = quality / quantity : 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?
R = region / radiation : 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?
S = severity scale : 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?
T = timing : 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?
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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. [3]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]
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 the arms (often inner left arm), the shoulders, and the 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. 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.
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
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.
Radiation of the pain
Typical locations for radiation of the pain are the arms (often inner left arm), shoulders, and neck into the jaw.
Severity of the pain
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.
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.
Relation to exertion
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
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.
Precipitating factors
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).
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.
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.
Relieving factors
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)[1]
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Class I1. In patients presenting with chest pain, a detailed symptom history, focused physical examination, and directed risk factor assessment should be performed. With this information, the clinician should estimate the probability of significant CAD (ie, low, intermediate, high). (Level of Evidence: B) |
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ESC Guidelines- Clinical Evaluation and ECG for Risk Stratification (DO NOT EDIT)[2]
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Class I1. 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) |
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See Also
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 [2]
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [3]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [4]
References
- ↑ 1.0 1.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) 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: 10351980
- ↑ 2.0 2.1 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.
- ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) 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.[1] PMID: 12515758
- ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)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.[2] PMID: 17998462