Chronic stable angina history and symptoms
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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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Risk calculators and risk factors for Chronic stable angina history and symptoms | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]
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.
P = provocation / palliation
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, and 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.
Q = quality / quantity
The nature of the sensation is usually not described as a "pain" but rather as a discomfort. It is often described 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.
R = region / radiation
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.
S = severity scale
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 if the discomfort interferes with activities, how bad the discomfort is when it is at its worst, and whether it forces the patient to sit down, lie down, or slow down.
T = timing
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 shrotness or breath or dyspnea.
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