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Chest Pain / Angina Pectoris: Difference between revisions
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Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved | Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease. | ||
by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease. | |||
== Introduction == | == Introduction == | ||
Three major coronary arteries supply the heart with oxygenated blood, the right coronary artery (RCA), the left anterior descending coronary artery (LAD) and the left circumflex artery (LCx). When the coronary arteries are affected by atherosclerosis and the lumen of the coronary arteries progressively narrow, a dysbalance between myocardial oxygen supply and myocardial oxygen consumption might occur, causing myocardial ischemia. This imbalance mainly occurs when oxygen demand increases due to exercise, increased heart rate, contractility or wall stress. | Three major coronary arteries supply the heart with oxygenated blood, the right coronary artery (RCA), the left anterior descending coronary artery (LAD) and the left circumflex artery (LCx). When the coronary arteries are affected by atherosclerosis and the lumen of the coronary arteries progressively narrow, a dysbalance between myocardial oxygen supply and myocardial oxygen consumption might occur, causing myocardial ischemia. This imbalance mainly occurs when oxygen demand increases due to exercise, increased heart rate, contractility or wall stress. | ||
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== Physical Examination == | == Physical Examination == | ||
There are no specific signs in angina pectoris. Physical examination of a patient with (suspected) angina pectoris is important to assess the presence of hypertension, | There are no specific signs in angina pectoris. Physical examination of a patient with (suspected) angina pectoris is important to assess the presence of hypertension, valvular heart disease, or hypertrophic obstructive cardiomyopathy. It should include the body-mass index, evidence of non-coronary vascular disease which may be asymptomatic, and other signs of co morbid conditions. Absence of palpable pulsations in the dorsal foot artery is associated with an 8 fold increase in coronary artery disease. | ||
valvular heart disease, or hypertrophic obstructive cardiomyopathy. It should include the body-mass index, evidence of non-coronary vascular disease which may be asymptomatic, | |||
and other signs of co morbid conditions. Absence of palpable pulsations in the dorsal foot artery is associated with an 8 fold increase in coronary artery disease. | |||
== Electrocardiogram (ECG) == | == Electrocardiogram (ECG) == | ||
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Some patients might be unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities, it might be difficult to interpret the exercise ECG. Finally, if the ECG made during exercise testing does not show any abnormalities angina pectoris becomes very unlikely. However, if the diagnosis is still in doubt, the following additional research may be performed. | Some patients might be unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities, it might be difficult to interpret the exercise ECG. Finally, if the ECG made during exercise testing does not show any abnormalities angina pectoris becomes very unlikely. However, if the diagnosis is still in doubt, the following additional research may be performed. | ||
# Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine. | # Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine. | ||
# Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite> | # Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake. <Cite>REFNAME13</Cite> | ||
# Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite> | # Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite> | ||
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== Coronary Angiography (CAG) == | == Coronary Angiography (CAG) == | ||
Coronary angiography (CAG) can assist in the diagnosis and the identification of treatment options for stable angina pectoris. During CAG, the coronary anatomy is visualized including the presence of coronary luminal stenoses. A catheter is inserted into the femoral artery or into the radial artery. The tip of the catheter is positioned at the beginning of the coronary arteries and contrast fluid is injected. The contrast is made visible by X ray and the images that are obtained are called angiograms. | Coronary angiography (CAG) can assist in the diagnosis and the identification of treatment options for stable angina pectoris. During CAG, the coronary anatomy is visualized including the presence of coronary luminal stenoses. A catheter is inserted into the femoral artery or into the radial artery. The tip of the catheter is positioned at the beginning of the coronary arteries and contrast fluid is injected. The contrast is made visible by X-ray and the images that are obtained are called angiograms. | ||
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== PCI == | == PCI == | ||
The procedure of PCI is similar to a CAG, except this time a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent | The procedure of PCI is similar to a CAG, except this time a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent the collapsing of the arteric wall and restenosis, a stent is often positioned at the site of the stenosis. | ||
== CABG == | == CABG == | ||