II. History
- See Chest Pain
- Ask Exercise History
- How often do you take Nitroglycerin?
- Documentation: Problem Summary
- History of Myocardial Infarction
- Ejection Fraction
- Revascularization procedures
- Angina (stability, severity, ischemic equivalents)
- Stress tests and imaging
- Secondary prevention goals at target?
III. Symptoms
- See Chest Pain
IV. Diagnosis
- See Angina Diagnosis
V. Types: Angina
- Chronic Angina (Fixed Obstruction)
- Resting Angina: 90% stenosis
- Pretreat higher endurance activities
- Take Nitroglycerin sublingual before activity
-
Unstable Angina (Plaque rupture)
- Myocardial Infarction high risk
- Often occurs with 2 weeks of symptom onset
- Myocardial Infarction high risk
- Vasospastic Angina (Prinzmetal's Angina)
VI. Labs: Biomarkers of chronic disease
VII. Management: Non-Pharmacologic
- Mental Stress confers Myocardial Ischemia risk
- Decreases Left Ventricular Ejection Fraction
- Doubles the risk of ischemic complications
- References
VIII. Management: Pharmacologic (Mechanisms of action)
- Nitroglycerin
-
Beta Blocker
- Reduces Heart Rate, reduces Afterload, decreases cardiac contractility
- Improves survival and decreases MI recurrence following recent MI or LV dysfunction
- Decreases Angina frequency and increases treadmill time
- Contraindications
- Decompensated Congestive Heart Failure (CHF)
- Do not combine with Calcium Channel Blockers (risk of AV Block)
-
Calcium Channel Blocker
- Reduces Afterload, prevents Vasoconstriction (no significant effect on vasodilatation)
- Short acting Dihydropyridines (e.g. Nifedipine) may paradoxically increase cardiovascular event rate
- Effective Antianginals, but do not decrease mortality
-
Aspirin (or other antiplatelet agents)
- Decreases Platelet aggregation
- Reduces cardiovascular event rate in Angina patients by one third
IX. Management: Protocol
- Step 1
- Aspirin 81 mg daily (or Platelet ADP Receptor Antagonist if Aspirin contraindicated)
- Sublingual Nitroglycerin prn and before Exercise
- Beta Blocker (e.g. Metoprolol)
- Step 2
- Increase Beta Blocker dose OR
- Consider Isosorbide monohydrate XR (once daily, least expensive long acting nitrate)
- Step 3
- Consider adding Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine), if no Systolic Dysfunction
- Step 4 (Refractory Angina)
- Consider Stress test or angiography again if need >2 agents
- Revascularization may be needed
- CABG is indicated in multi-vessel disease, Diabetes Mellitus, >50% left main Coronary Artery
- PCI may improve symptoms but does not reduce mortality in stable coronary disease
- May be preferred in Stable Angina when Antianginals are not tolerated or taken consistently
- Rajkumar (2023) N Engl J Med 389(25): 2319-30 [PubMed]
X. Management: Other measures
- Ranolazine (Ranexa)
- Not more effective than other anti-Anginal medications
- Risk of QT Prolongation, multiple Drug Interactions and high expense (>$500/month)
- Used in combination with other agents above
- Reduces Angina frequency (by one less episode/week)
- Chaitman (2004) JAMA 291:309-16 [PubMed]
XI. Management: Comorbidity
XII. Management: Patient Instructions
- Rehearse what to do:
- Chest Pain
- Take one Nitroglycerin sublingually at onset
- Chew one Aspirin 162 to 325 mg (in whom there is no contraindication)
- Seek immediate medical attention if symptoms worsen or do not improve within 5 minutes
- Continue to take Nitroglycerin every 5 minutes up to a total of 3 doses as needed for Chest Pain
- Transient Ischemic Attacks or Cerebrovascular Accident
- Immediate emergency department evaluation
- Chest Pain
- Review Prevention
- See Cardiac Risk Reduction
- Increase activity
- Omega-3-Fatty Acids as of 2021 do not appear to significantly lower Cardiovascular Risk
- (2021) Presc Lett 28(1): 1-2
- Nicholls (2020) JAMA 324(22):2268-80 [PubMed]
- Testing (review if current, esp. if high risk)
- Stress Testing every 3-5 years
- Coronary Artery Disease Biomarkers (see above) every 3-5 years
- Secondary prevention labs
- Lipid profile
- Hemoglobin A1C
- Review Goals
- Blood Pressure <130/80
- LDL Cholesterol <70-100 mg/dl
- HDL Cholesterol >45 mg/dl
- Body Mass Index optimization
- Hemoglobin A1C < 7.0
- Review Medications
- Aspirin
- ACE Inhibitor
- Beta Blocker
- Antianginals
- Follow-up
- Primary care visits every 6 months if stable
- Cardiology every 1-2 years
- Handouts
- Updated medication list and after visit summary
- Mediterranean Diet
Images: Related links to external sites (from Bing)
Related Studies
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (CHV) | chest pain caused by coronary heart disease |
| Definition (MEDLINEPLUS) |
Angina is chest pain or discomfort you feel when there is not enough blood flow to your heart muscle. Your heart muscle needs the oxygen that the blood carries. Angina may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw, or back. Angina is a symptom of coronary artery disease (CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow. There are three types of angina:
Not all chest pain or discomfort is angina. If you have chest pain, you should see your health care provider. NIH: National Heart, Lung, and Blood Institute |
| Definition (NCI) | Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.(NIH Roadmap Cardiovascular Data Standards Working Group) |
| Definition (NCI) | A heart condition marked by paroxysms of chest pain due to reduced oxygen to the heart. |
| Definition (NCI_CTCAE) | A disorder characterized by substernal discomfort due to insufficient myocardial oxygenation. |
| Definition (MSH) | The symptom of paroxysmal pain consequent to MYOCARDIAL ISCHEMIA usually of distinctive character, location and radiation. It is thought to be provoked by a transient stressful situation during which the oxygen requirements of the MYOCARDIUM exceed that supplied by the CORONARY CIRCULATION. |
| Definition (CSP) | recurring thoracic pain or discomfort which occurs when a part of the heart does not receive enough blood; usually caused by exertion or excitement. |
| Concepts | Finding (T033) |
| MSH | D000787 |
| ICD9 | 413 |
| ICD10 | I20 , I20.9, I20.8 |
| SnomedCT | 17828002, 194835008, 155307004, 367416001, 194830003, 194832006, 194839002, 194828000, 225566008 |
| LNC | LA14275-4 |
| English | Anginal pain, Angina Pectoris, Angor Pectoris, Stenocardia, Stenocardias, ANGINA PECTORIS, ANGINAL PAIN, ANGINAL SYNDROME, Angina pectoris NOS, Ischaemic ht dis - angina, Ischemic ht dis - angina, Angina pectoris, unspecified, anginal pain, angina pectoris (diagnosis), angina pectoris, Angina syndrome, Angina of effort, Angina NOS, Angina Pectoris [Disease/Finding], pectoris angina, Pain;angina, anginal syndrome, angina, angor pectoris, cardiac angina, ischemic chest pain, pain angina, anginas, Angina pectoris (disorder), Anginal discomfort, Stenocardia (disorder), Angina pectoris NOS (disorder), Ischaemic chest pain (disorder), Angina, Angina pectoris, ANGINA, Chest pain - cardiac, chest pain ischemic, Ischemic chest pain (diagnosis), Anginal syndrome, Cardiac angina, Ischaemic heart disease - angina, Ischemic heart disease - angina, AP - Angina pectoris, Ischaemic chest pain, Ischemic chest pain, Ischemic chest pain (finding), Angina (disorder), Ischaemic heart dis with angina, Ischemic heart dis with angina, Ischemic heart disease with angina, Ischaemic heart disease with angina, stenocardia, chest; pain, ischemic, pain; chest, ischemic, syndrome; anginal, anginal; syndrome, Angina pectoris, NOS, Angina pectoris (disorder) [Ambiguous], Angina, NOS, Angina, cardiac, angina pain |
| Portuguese | ANGINA PECTORIS, Angina, Dor anginosa, Dor torácica isquémica, Síndrome anginosa, Desconforto anginoso, DOR ANGINOSA, SINDROME ANGINOSO, Angor do Peito, Angina de peito, Angina Pectoris, Angor Pectoris, Estenocardia |
| German | ANGINA PECTORIS, Anginabeschwerden, ischaemischer Brustschmerz, Anginasyndrom, Angina, Anginaschmerz, ANGINA PECTORIS SYNDROM, Angina pectoris, nicht naeher bezeichnet, HERZSCHMERZEN, Angina pectoris, Angor pectoris, Stenokardie |
| Dutch | angineuze pijn, angineus ongemak, anginasyndroom, ischemische pijn op de borst, angina, ischemische pijn op borst, angineus syndroom, stenocardie, Ischemische hartziekte met angina, angineus; syndroom, borst; pijn, ischemisch, pijn; borst, ischemisch, syndroom; angineus, Angina pectoris, niet gespecificeerd, angina pectoris, Angina pectoris, Angor pectoris, Stenocardie |
| French | Douleur angineuse, Syndrome d'angor, Douleur thoracique ischémique, Gêne angineuse, Angor, Maladie d'Heberden, Angine de poitrine, Sténocardie, Angor pectoris, ANGINE DE POITRINE, DOULEUR ANGINEUSE, SYNDROME ANGINEUX |
| Italian | Angina, Sindrome anginosa, Dolore anginoso, Dolore toracico ischemico, Fastidio anginoso, Stenocardia, Angina pectoris |
| Spanish | Angina, Síndrome anginoso, Dolor isquémico, Dolor isquémico del pecho, Dolor anginoso, Molestia angoroide, cardiopatía isquémica (trastorno), ANGINOSO, SINDROME, ANGOR, DOLOR ANGINOSO, cardiopatía isquémica, angina de pecho, SAI (trastorno), estenocardia (trastorno), Angina pectoris NOS, estenocardia, angina pectoris, angina de pecho, SAI, angina cordis, Angina de Pecho, angina de pecho (trastorno), angor (trastorno), angina de pecho, angina de pecho (concepto no activo), angina, angor pectoris, angor, dolor torácico isquémico (hallazgo), dolor torácico isquémico, síndrome anginoso, Angina de pecho, Estenocardia, Angina Pectoris, Angor de Pecho |
| Japanese | アンギナ, 狭心症性不快感, 狭心痛, 虚血性胸痛, 狭心症症候群, ｷｮｳｼﾝｼｮｳ, ｷｮｳｼﾝﾂｳ, ｷｮｹﾂｾｲｷｮｳﾂｳ, ｱﾝｷﾞﾅ, ｷｮｳｼﾝｼｮｳｼｮｳｺｳｸﾞﾝ, ｷｮｳｼﾝｼｮｳｾｲﾌｶｲｶﾝ, 狭心症, 胸部苦悶 |
| Swedish | Kärlkramp |
| Czech | angina pectoris, Angina pectoris, Ischemická bolest na hrudi, Syndrom anginy pectoris, Stenokardie, Anginózní diskomfort, Anginózní bolest, stenokardie, AP |
| Finnish | Rasitusrintakipu |
| Russian | STENOKARDIIA, GRUDNAIA ZHABA, ГРУДНАЯ ЖАБА, СТЕНОКАРДИЯ |
| Korean | 상세불명의 협심증, 협심증 |
| Croatian | ANGINA PEKTORIS |
| Polish | Dusznica bolesna, Dławica piersiowa, Dławica stabilna |
| Hungarian | Ischaemiás mellkasi fájdalom, Angina, Anginás fájdalom, Stenocardia, Angina pectoris, Angina syndroma, Ischaemiás mellkasfájdalom, Anginás discomfort |
| Norwegian | Angina pectoris, Hjertekrampe |
Ontology: Myocardial Ischemia (C0151744)
| Definition (MSHCZE) | Onemocnění srdce charakterizované nedostatečným prokrvením – ischemií. Porušeno je zásobení kyslíkem (hypoxie) a živinami i odvádění zplodin látkové výměny (vzniká lokální acidóza, iontové změny). Podkladem je zúžení (popř. uzávěr) koronárních tepen obv. aterosklerózou (aterosklerotický plát, trombóza, spasmus). Hlavními projevy ICHS jsou zejména angina pectoris a infarkt myokardu. Označují se jako bolestivé (algické) formy. Dalšími projevy ICHS mohou být arytmie nebo srdeční selhání (ischemie zvyšuje elektrickou nestabilitu myokardu a má negativní působení na kontraktilitu). K vzniku ICHS přispívají faktory, které jsou rizikovými faktory aterosklerózy (zejm. hyperlipoproteinemie, hypertenze, diabetes, kouření, stres atd.). V diagnóze se uplatňuje EKG, zátěžové testy (ergometrie), klidová i zátěžová echokardiografie, thalliový scan, biochemické vyšetření u akutní ischemie (infarktu). Zúžení koronárních tepen se zjišťuje koronarografií. V léčbě se používají nitráty, betablokátory, antagonisté kalcia, antiagregační léčba aj. V řadě případů se provádějí zákroky přímo na věnčitých tepnách – na otevřeném srdci (bypass) nebo perkutánně katetrizací (PTCA, stent). (cit. Velký lékařský slovník online, 2012 http://lekarske.slovniky.cz/ ) |
| Definition (NCI) | A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries, to obstruction by a thrombus, or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (myocardial infarction). |
| Definition (CSP) | blood deficiency in the myocardium caused by a constriction or obstruction of its blood vessels; frequently occurs in conjunction with hypoxia, which is reduction in oxygen supply. |
| Definition (MSH) | A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (CORONARY ARTERY DISEASE), to obstruction by a thrombus (CORONARY THROMBOSIS), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (MYOCARDIAL INFARCTION). |
| Concepts | Disease or Syndrome (T047) |
| MSH | D017202 |
| ICD9 | 410-414.99 |
| ICD10 | I20-I25.9 , I20-I25 |
| SnomedCT | 155303000, 41702007, 32598000, 155322009, 194795001, 195540001, 194878003, 271430002, 233822007, 2610009, 414545008, 414795007 |
| LNC | LP31567-8, MTHU024507 |
| English | Disease, Ischemic Heart, Diseases, Ischemic Heart, Heart Disease, Ischemic, Heart Diseases, Ischemic, Ischemic Heart Disease, Ischemic Heart Diseases, Ischemia, Myocardial, Myocardial Ischemia, MYOCARDIAL ISCHAEMIA, Ischemias, Myocardial, Myocardial Ischemias, MYOCARDIAL ISCHEMIA, Ischaemic heart disease NOS, Ischaemic heart diseases, Ischemic heart diseases, HEART DIS ISCHEMIC, ISCHEMIC HEART DIS, Cardiac ischaemia, myocardial ischemia (diagnosis), myocardial ischemia, IHD, Ischemia myocardial, Myocardial Ischemia [Disease/Finding], cardiac ischaemia, Disease;ischaemic heart, ihd, cardiac ischemia, myocardial ischaemia, myocardial ischemia/hypoxia, Ischemic heart diseases (I20-I25), Ischaemic heart disease (disorder), Ischemic heart disease NOS (disorder), Myocardial ischaemia (disorder), Ischaemia myocardial, Ischaemic heart disease NOS (disorder), ischemic heart disease, ischemic heart disease (diagnosis), ISCHEMIC HEART DISEASE, DISEASE, ISCHEMIC HEART, HEART DISEASE, ISCHEMIC, ischemia; heart, ischemia; myocardial, myocardium; ischemic, Ischemic heart disease, NOS, Ischaemic heart disease, NOS, Myocardial ischemia, NOS, Ischemic heart disease, IHD - Ischaemic heart disease, IHD - Ischemic heart disease, Ischaemic heart disease, Myocardial ischaemia, Myocardial ischemia, Cardiac ischemia, Ischemic heart disease (disorder), Myocardial ischemia (disorder), Ischemic heart disease NOS, Disease;ischemic heart, ischaemic heart disease |
| Portuguese | ISQUEMIA MIOCARDICA, Isquemia cardíaca, Isquemia do miocárdio, Cardiopatia isquémica, Cardiopatia Isquêmica, Isquemia miocárdica, Doença Isquêmica do Coração, Isquemia Miocárdica |
| Spanish | ISQUEMIA MIOCARDICA, ECI, Isquemia miocárdica, Enfermedad isquémica cardiaca, Isquemia cardiaca, Cardiopatía isquémica, cardiopatía isquémica, SAI (trastorno), Ischaemic heart disease NOS, cardiopatía isquémica, SAI, cardiopatía isquémica (concepto no activo), Ischemic heart disease NOS, enfermedad cardíaca isquémica, SAI, Isquemia de miocardio, cardiopatía isquémica (trastorno), cardiopatía isquémica, enfermedad cardíaca isquémica, enfermedad isquémica del corazón, isquemia miocárdica (trastorno), isquemia miocárdica, Cardiopatía Isquémica, Isquemia Miocárdica |
| Dutch | hartischemie, IHD, ischemische hartziekte, ischemie myocard, ischemische hartaandoening, ischemie; hart, ischemie; myocard, myocard; ischemie, myocardischemie, Hartziekte, ischemische, Ischemie, myocard-, Ischemische hartziekte, Myocardischemie |
| French | Ischémie cardiaque, Maladie cardiaque ischémique, IC, Cardiopathie ischémique, ISCHEMIE DU MYOCARDE, Ischémie myocardique, Ischémie du myocarde |
| German | Myokardischaemie, ischaemische Herzkrankheit, IHD, kardiale Ischaemie, MYOKARDIALE ISCHAEMIE, myokardiale Ischaemie, Herzkrankheit, ischämische, Herzmuskelischämie, Ischämie, Myokard-, Ischämische Herzkrankheit, Myokardischämie |
| Italian | Cardiopatia ischemica, Ischemia cardiaca, Ischemia miocardica |
| Japanese | 心虚血, ｼﾝｷｮｹﾂ, ｷｮｹﾂｾｲｼﾝｼｯｶﾝ, ｼﾝｷﾝｷｮｹﾂ, 心筋虚血, 虚血-心筋, 虚血性心疾患, 心疾患-虚血性, 心臓疾患-虚血性, 虚血性心臓疾患 |
| Swedish | Myokardischemi |
| Finnish | Sydänlihaksen iskemia |
| Russian | ISHEMICHESKAIA BOLEZN' SERDTSA, SERDTSA ISHEMICHESKAIA BOLEZN', ISHEMIIA MIOKARDA, MIOKARDA ISHEMIIA, MIOKARDIAL'NAIA ISHEMIIA, ИШЕМИЧЕСКАЯ БОЛЕЗНЬ СЕРДЦА, ИШЕМИЯ МИОКАРДА, МИОКАРДА ИШЕМИЯ, МИОКАРДИАЛЬНАЯ ИШЕМИЯ, СЕРДЦА ИШЕМИЧЕСКАЯ БОЛЕЗНЬ |
| Czech | Ischemie myokardu, Myokardiální ischemie, Ischemická choroba srdeční, Srdeční ischemie, ischémie myokardu, myokard - ischémie, ICHS, ischemická choroba srdeční |
| Croatian | MIOKARD, ISHEMIJA |
| Polish | Niedokrwienie mięśnia sercowego, Choroba niedokrwienna serca |
| Hungarian | Cardialis ischaemia, Szív ischaemia, Szív ischaemiás betegsége, myocardialis ischaemia, Ischaemiás szívbetegség, Szívizom ischaemiája, Szívizom ischaemia, ISzB |
| Norwegian | Ischemisk hjertesykdom, Myokardiskemi, Myokardischemi, Iskemisk hjertesykdom |
Ontology: Stable angina (C0340288)
| Definition (MSH) | Persistent and reproducible chest discomfort usually precipitated by a physical exertion that dissipates upon cessation of such an activity. The symptoms are manifestations of MYOCARDIAL ISCHEMIA. |
| Definition (NCI) | Angina pectoris without a recent change in frequency or pattern. Angina is relieved by rest and/or sublingual/oral/transdermal medications.(NIH Roadmap Cardiovascular Data Standards Working Group) |
| Definition (NCI) | Angina pectoris which has not recently changed in frequency, duration or intensity. Stable angina pectoris is relieved by rest or administration or oral, sublingual or transdermal antianginal medications. |
| Definition (NCI_CDISC) | Angina pectoris which has not recently changed in frequency, duration or intensity. Stable angina pectoris is relieved by rest or administration of oral, sublingual or transdermal antianginal medications. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D060050 |
| SnomedCT | 155312003, 194838005, 233819005 |
| Dutch | stabiele angina pectoris |
| German | stabile Angina pectoris, Chronische stabile Angina, Angina, stabile, Angina pectoris, stabile |
| Italian | Angina pectoris stabile, Angina stabile |
| Portuguese | Angina de peito estável, Angina Estável Crônica, Angina Estável |
| Spanish | Angina de pecho estable, Angina Estable Crónica, Angina Estable, angina de pecho estable (trastorno), angina de pecho estable |
| Japanese | 安定狭心症, ｱﾝﾃｲｷｮｳｼﾝｼｮｳ |
| English | Stable Angina, Stable Angina Pectoris, stable chronic angina, angina stable, angina chronic stable, stable angina, chronic stable angina, Stable angina pectoris, Angina, Stable, Anginas, Chronic Stable, Chronic Stable Anginas, Anginas, Stable, Stable Angina, Chronic, Pectori, Stable Angina, Chronic Stable Angina, Stable Anginas, Chronic, Stable Angina Pectori, Stable Anginas, Angina Pectoris, Stable, Angina Pectori, Stable, Pectoris, Stable Angina, Angina, Chronic Stable, Angina, Stable [Disease/Finding], Stable angina, stable angina (diagnosis), STABLE ANGINA, Stable angina (disorder) |
| Czech | Stabilní angina pectoris, stabilní angina pectoris, chronická stabilní angina pectoris |
| Hungarian | Stabil angina pectoris |
| French | Angine de poitrine chronique stable, Angine de poitrine stable chronique, Angine de poitrine stable, Angor chronique stable, Angor stable chronique, Angor stable |
| Russian | STENOKARDIIA STABIL'NAIA, СТЕНОКАРДИЯ СТАБИЛЬНАЯ, ХРОНИЧЕСКАЯ СТАБИЛЬНАЯ СТЕНОКАРДИЯ, KHRONICHESKAIA STABIL'NAIA STENOKARDIIA |
| Polish | Stabilna dusznica bolesna, Dusznica bolesna stabilna, Dusznica stabilna, Stabilna dławica piersiowa |
| Norwegian | Stabil angina, Kronisk stabil angina, Angina pectoris, stabil, Stabil angina pectoris |
| Croatian | Angina pektoris, stabilna |
Ontology: Anti-anginal [EPC] (C1874267)
| Concepts | Pharmacologic Substance (T121) |
| English | Anti-anginal [EPC], Anti-anginal |
