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Management of Stable Angina
Scott A. Phillips, M.D.AnMed Health Carolina Cardiology
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Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made
regarding financial relationships with commercial interests within the last 12 months.
I , Scott Phillips have no relevant financial relationships or affiliations with commercial interests to disclose.
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Cardiac Causes-Ischemic vs. Non-ischemic
Non-Cardiac Causes-Pulmonary, GI, Musculoskeletal, Dermatology
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1. Chest Wall Pain• Sharp, Precisely localized• Reproducible: Palpation, movement
2. Pleuritic or Respiratory CP• Somatic pain, Sharp• Worse with breathing/coughing
3. Visceral CP• Poorly localized, aching, heaviness
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Non-cardiac Chest Pain
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Most common cause of non-cardiac chest pain
Causes:-Esophagitis/Gastritis-Ulcers-Reflux-Esophageal Spasm (can be relieved with Nitro)-Pancreatitis-Gall bladder
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Pleuritic (worse with breathing/coughing) Sharp/stabbing pain
Causes:-Infections (bronchitis/pneumonia)-Pleural effusions (fluid around the lung)-Pulmonary Emboli (blood clots)-Pneumothorax (collapsed lung)-Malignancy
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Costocondritis (inflammation of cartilage) Rib fracture Myalgia (muscle pains)
Pain is worse with movements. May be reproducible with palpation.
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Shingles (Herpes Zoster)
Focal, dermatomal pain.
Constant, burning/tingling pain.
Pain starts several days before a rash is present.
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Shingles
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Ischemic:-Myocardial infarction (ACS) -Stable angina-Coronary vasospasm -Aortic stenosis -Hypertrophic cardiomyopathy
Non-ischemic:-Pericarditis -Aortic dissection
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Causes:-congenital-calcification-rheumatic fever
Symptoms are typically exertional.
Often associated with signs of heart failure.
May also be associated with passing out (syncope).
Loud systolic murmur heard on exam.
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Abnormal thickening of the heart muscle.
Hereditary
Causes outflow obstruction from the left ventricle.
Exertional chest pain, shortness of breath, and passing out, death.
Loud murmur on exam.
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Sudden onset of SEVERE ripping/tearing chest pain
Radiates through to the back
Associated with high blood pressure.
Feeling of doom
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Prinzmetal’s Angina
Spasms of the coronary arteries.
More common in women
Occurs at rest.
Can look like a heart attack on EKG.
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Causes-Infections (Viral, tuberculosis)-Kidney failure-Autoimmune diseases-Radiation-Heart attacks (Dressler’s Syndrome)
Symptoms-Positional/pleuritic chest pain
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Pericarditis
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Coronary Artery Disease
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Thrombus
Plaque rupture
Plaque Rupture
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Aspirated blood clot and plaque during MI
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Characteristics Location Severity Duration Associated symptoms Radiation of pain Triggers (exertion, emotional distress) Relieving features (rest, aspirin, nitro)
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Chest pain (heavy, burning, tight, pressure, sharp, tingling, stabbing, throbbing)
Jaw/neck pain Arm pain/numbness Back pain Shortness of breath Nausea/vomiting, hiccups Sweating
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Typical Anginal Pain Distribution
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Class I
Class II
Class III
Class IV
No angina with ordinary physical activity
Angina with strenuous/prolonged exertionEarly-onset, limitation of ordinary activity (2 blocks/1 flight)
Marked limitation of ordinary activity
Inability to carry out any physical activity without angina
Angina occurs at rest
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Pretest Probability
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Does the pt fit into one of the following?1. Noncardiac CP and low pretest probability
2. Diagnosis of angina is established (high pretest prob)
3. Diagnosis is still not clear…(intermediate pretest prob)
• No further testing needed.
• Pt does not have angina
• No further diagnostic testing needed.
• Pt needs risk stratification for prognosis
• Consider the following tests to make a diagnosis…
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Algorithm for Evaluation and Management of Patients Suspected of Having ACS.
Anderson J L et al. Circulation. 2011;123:e426-e579
Copyright © American Heart Association, Inc. All rights reserved.
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71 w/m with 2 month h/o exertional chest pressure.
Presented to PCP office with worsening of symptoms during exertion.
PMHx: Hyperlipidemia, HTN, CRI, ED
Meds: Crestor, Prilosec, Cialis
Allergies: NKDA
FHx: None
SocHx: smoker
Exam: Afeb, 130/82, 85, 16, (Normal exam)
Labs: BUN 20, Cr 1.0, Gluc 99, WBC 5, HCT 43, Plt 140
CXR: normal
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63 w/m with 3 month h/o mild intermitent exertional chest pain.
Worse and more frequent over past week.
Severe episode with SOB prompting first time visit to PCP’s office.
PMHx: HTN
Meds: Lisinopril, ASA.
Allergies: NKDA
FHx: CVA
SocHx: non-smoker, rare EtOH, no illicits, pharmacist.
Exam: Afeb, 149/98, 115, 18, 95% 2L NC
NAD
Tachycardic, 1/6 harsh syst murmur RUSB, JVD to jaw
Bilateral rales half way up lung fields.
Trace pedal edema, warm, 2+ pulses
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WBC 12, HCT 43, Plt 333
BUN 21, Cr 0.8, Gluc 183
HgA1C 7.8
Chol 177, Trig 161, LDL 115, HDL 30
Trop 0.87, 1.03
CXR: pulmonary edema
ECHO: EF 20%, mild AS
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86 w/m with 6 month h/o exertional left sided chest pressure and DOE.
Worsening over past 2 weeks.
Presents to PCP after 2 episodes of resting pain.
PMHx: HTN, COPD, Parkinson’s, BPH, chronic anemia, OA.
Meds: ASA, lisinopril, calcium, eye drops, combivent.
Allergies: NKDA
FHx: N/C
SocHx: Lives with care taker, 3 sons, remains fairly active, non-smoker.
Exam: Afeb, 105/70, 70, 14
Thin with mild Parkinsonian features.
2/6 syst murmur LSB.
Labs: BUN 19, Cr 0.5, WBC 6, HCT 36, MCV 92, Plt 188
Imaging: CXR normal
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76 w/f with 1 month h/o intermittent non-exertional burning mid epigastric/substernal chest discomfort partially relieved with TUMS.
PMHx: HTN, hyperlipidemia, borderline DM
PSHx: cholecystectomy and hysterectomy.
Meds: ASA, Toprol, lisinopril, pravastatin.
Allergies: NKDA
FHx: CAD (father/brother)
SocHx: Quit smoking 25 yrs ago.
Exam: Afeb, 164/92 (didn’t take a.m. meds), 59, 16
Otherwise normal exam.
Labs: Normal
Imaging: CXR normal.
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Questions ??????