Chronic stable angina physical examination
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Overview
A good history and physical examination is the key to diagnosis. If the history is suggestive of angina, it is desirable to assess its severity to help guide further diagnostic studies and treatment. The New York Heart Association functional classification has been largely replaced by the Canadian Cardiovascular Society functional classification. Physical examination may be normal but helps in forming a differential diagnosis of chest pain
Clinical Evaluation of Angina Pectoris
History
Clinical evaluation of angina should always start by obtaining a good history. Classic angina is angina associated with exercise or emotional stress and relieved by rest or nitroglycerin. However, it should be noted that in some patients, dyspnea, not chest discomfort, with exercise or stress may be the presentation of angina and is termed as angina equivalent. If the history is suggestive of angina, its severity should be assessed based on the Canadian Cardiovascular Society functional classification.
During initial evaluation of the patient with possible angina, the physician should also determine whether risk factors for atherosclerotic coronary artery disease (hyperlipidemia, diabetes mellitus, hypertension, cigarette smoking, obesity and a family history of premature coronary artery disease) are present, since these risk factors not only increase the likelihood that the patient has underlying coronary disease but also serve as potential targets for intervention.
In women, the menstrual status as well as hormone replacement therapy (HRT) should be assessed, since the risk of coronary artery disease (CAD) rises in postmenopausal women who are not receiving estrogen (or estrogen / progesterone combinations) replacement therapy. Inquiries should be made for a history of peripheral vascular disease, or symptoms thereof, such as leg circulation and transient ischemic attacks, because the prevalence of CAD is substantially higher in patients with peripheral vascular disease, carotid artery disease and thoraco-abdominal aortic aneurysms.
As mentioned earlier in pathophsiology section, although coronary artery disease (CAD) is, by far, the most frequent cause of angina pectoris, in the absence of atherosclerotic obstructive coronary artery disease (CAD), typical angina can be a symptom of hypertrophic cardiomyopathy, ischemic or non-ischemic dilated cardiomyopathy, restrictive cardiomyopathy and pulmonary artery hypertension.
Clinical evaluation and appropriate investigations establish the diagnosis in such patients. According to risk factor management strategy, the summary of risk factors for coronary artery disease as follow;
- Non-modifiable risk factors
- Age (more frequently in elderly)
- Gender; more in male gender. Post menopausal women have almost equal risk for coronary artery disease.
- Family history of premature coronary artery disease
- Modifiable risk factors
- Cigarette smoking
- Abnormal lipid levels (high LDL, low HDL cholesterol)
- Diabetes mellitus
- Sedentary lifestyle
- Hypertension (especially uncontrolled hypertension)
- Cerebrovascular disease
- Peripheral vascular disease
- Obesity
Physical examination
The physical examination may be entirely normal in patients with stable angina pectoris, although hypertension, a major risk factor for coronary artery disease (CAD) may be present.
Examination of the cardiovascular system during ischemia, however, may reveal elevated blood pressure, transient third heart sound (S3 - ventricular filling sound) and fourth heart sound (S4 - atrial filling sound), a sustained outward (dyskinetic) systolic movement of the left ventricular apex, a murmur of mitral regurgitation, and paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave.
The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular aortic stenosis, cardiomyopathy and pulmonary hypertension).
Cardiovascular assessment should also include the examination of peripheral arterial pulses, evaluation of retinal fundus for vascular changes and screening for risk factors of coronary artery disease (CAD), stigmata of genetic dyslipidemia syndromes such as tendon xanthomas, xanthelasma, and corneal arcus, particularly in patients under 50 years of age.
Since the presence of noncoronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination of peripheral arterial pulses, auscultation of the carotid arteries for bruits and palpation of the abdomen for aneurysm are important in clinical evaluation.
ACC / AHA Guidelines- History and Physical (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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- ↑ Gibbons RJ, Chatterjee K, Daley J, et al. 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. 1999; 99: 2829–2848. PMID 10351980