Angina Pectoris - An Approach To Chest Pain & Acute Coronary Syndrome | Stable & Unstable Angina |

Summary

This script discusses the classification and evaluation of angina, distinguishing between classical, atypical, and non-anginal chest pain. It outlines the importance of a high suspicion for cardiac issues in patients with chest pain, emphasizing the need for focused history, physical exams, and vital checks. The script details diagnostic procedures, including ECG, cardiac enzymes, and chest X-rays, and the administration of aspirin and nitroglycerin. It also covers the diagnosis of aortic dissection, the interpretation of ECG results, and the use of stress testing to uncover hidden cardiac issues. Finally, it touches on the decision-making process for interventions like coronary artery bypass graft based on the extent of coronary artery disease revealed by angiography.

Takeaways

• 📚 Angina can be classified into classical, atypical, and non-anginal pain based on specific characteristics.
• 🏃‍♂️ Classical angina is characterized by pressure or crushing chest pain that radiates to the jaw and left arm, provoked by exercise or emotional stress, and relieved by nitroglycerin or rest.
• 🤔 Atypical angina presents with two of the classical angina features, while non-anginal pain has one or none of these features.
• 👨‍⚕️ When evaluating chest pain, the level of suspicion for cardiac pathology should be high, and a focused history, physical exam, vitals check, and venous blood gas analysis should be conducted.
• 🚑 Unstable patients with chest pain require immediate hemodynamic stabilization, while stable patients need further diagnostic tests like ECG, cardiac enzymes, and chest X-ray.
• 💊 Aspirin should be administered promptly to reduce mortality in chest pain patients unless there's a risk of aortic dissection.
• 🩺 Physical examination should include checking blood pressure in both arms to assess the risk of aortic dissection.
• 🧬 Cardiac markers, particularly troponin and CKMB, are crucial for diagnosing myocardial infarction (MI) and differentiating between initial and subsequent infarctions.
• 🏥 If ECG and cardiac enzymes are normal but chest pain is suspected to be cardiac, stress testing can help identify ischemia by inducing stress on the heart.
• 🔍 Coronary angiography is used to visualize the extent of coronary artery stenosis and guide treatment decisions such as coronary artery bypass graft.

Q & A

What are the three characteristics of classical angina?

Classical angina is characterized by typical quality pressure or crushing substernal chest pain, pain that radiates toward the jaw and the left arm, and pain that is provoked by exercise and emotional upheaval, and is relieved by nitroglycerin or rest.

How is atypical angina different from classical angina?

Atypical angina has two of the classical angina characteristics, whereas non-anginal pain has either one or none of the classical angina features.

What are some examples of atypical presentations of angina mentioned in the script?

Cubitus angina, which appears when the patient lies flat and goes away when they sit up, and warm-up angina, which appears when the patient starts exercising but disappears later during exercise.

What should be the first steps when a patient presents with chest pain?

The first steps should include taking a focused history, performing a physical exam, checking vitals, and obtaining venous blood samples.

Why is it important to check blood pressure in both arms during a physical exam for chest pain?

Checking blood pressure in both arms is important because a difference in blood pressure between the two arms may indicate an aortic dissection, which is a serious condition.

What is the significance of administering aspirin to a patient with chest pain?

Administering aspirin can reduce mortality as it thins the blood and inhibits clotting, which is beneficial in cases of myocardial infarction, unless the risk of aortic dissection is high.

Why should nitroglycerin be used with caution in certain patients?

Nitroglycerin should be used with caution in patients who are hypotensive or bradycardic because it can cause further hypotension by vasodilating the blood vessels, which decreases preload to the right side of the heart and can worsen heart function.

What is the role of oxygen administration in a patient with chest pain?

Administering oxygen ensures that the blood reaching the heart is fully saturated with oxygen, which is crucial when the coronary arteries are not feeding the heart properly.

How can ST segment elevation on an ECG indicate a myocardial infarction?

ST segment elevation on an ECG indicates a myocardial infarction because it shows that there is permanent damage to the heart, suggesting that the blood supply to the heart has been severely compromised.

What is the significance of troponin and CKMB levels in diagnosing myocardial infarction?

Troponin is a highly specific marker for myocardial infarction and is elevated within six hours of an MI, remaining elevated for one to two weeks. CKMB, while not as specific, returns to normal within 48 to 72 hours, making it useful for diagnosing reinfarction if the initial MI was diagnosed using troponins.

What is the purpose of stress testing in patients with chest pain?

Stress testing is used to induce stress on the heart, which can reveal ischemia or hypoxia that may not be apparent at rest. This helps in diagnosing cardiac pathology that was not evident from the initial ECG or cardiac markers.

How does coronary angiography help in managing chest pain?

Coronary angiography visualizes the coronary arteries and identifies the extent of stenosis, which is crucial for deciding the appropriate intervention, such as coronary artery bypass graft, to manage the patient's condition.