Chronic stable angina history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3], 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 describe the sensation as discomfort rather than physical pain. The best method to characterize this discomfort/pain is through the PQRST system

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
• 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.

Q = Quality/Quantity

• 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.

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:

• 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.

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 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, 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.
Class II	Minimal limitation: There is slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in 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. 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)

History and Physical (DO NOT EDIT)

Class I

"1. 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)"

ESC Guidelines- Clinical Evaluation (DO NOT EDIT)

“

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)

”

Guidelines Resources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

References

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