Diagnosis
Hx is consistent with chronic stable angina, not ACS.
OPQRST-A.
Angina type (Typical, Atypical, Nonspecific)?:
CVD risk factors in this pt are:_____________
Pretest Probability of CAD: High / Intermediate / Low / Very low
HEART score: (The HEART score outperforms the TIMI score).
Differential diagnosis.
Pleuritic chest pain? recent URI? hemoptysis? recent surgery or procedures?
Any PE risk factors?
R/o life-threatening Ddx: PE, PTX,
Any illicit drug use (e.g. cocaine, Meth, etc.)?
Physical Exam: Heart (m/r/g), chest wall, breast exam prn, lungs, BP in both arms (>10 mmHg difference suggests aortic dissection);
Labs/Imaging/Studies:
–ECG, CXR (eval for PNA, widened mediastinum); TSH, CBC, CMP, BNP;
-Troponins and CK (if pt presents with s/sx suggestive of MI).
-D-dimer if PE suspected.
-HbA1c, Fasting Lipid Panel, TSH (to risk stratify or assess for cardiovascular risk factors)
-Stress Test (if intermediate pre-test probability)
-TTE as needed.
-CT scan as needed.
Medical therapy
Nitroglycerin sublingual PRN.
ASA
Beta-blockers / CCB (If HR and BP allow)
ACE-I in patients with DM, low EF, or HTN
Statin (High-Intensity) to keep LDL < 100 (goal is <70)
Long-acting nitrates e.g. Isosorbide mononitrate, for angina
Treat modifiable RF /aggravating factors like DM, HTN, HLD, anemia, thyrotoxicosis, hypothyroidism.
Ranolazine can be added in patients with persistent symptoms. It’s not used as a first-line agent.
Revascularization therapy
Reserved for patients who remain symptomatic after optimal medical therapy. Cardiac catheterization not required but may be done per cardiology if the stress test is positive or pre-test probability is high.
PCI (angiography and stent placement).
CABG surgery.
Secondary Prevention
Smoking cessation; BP control; dyslipidemia treatment; Exercise; weight loss if overweight/obese
Who to send to the ED: Patients with life-threatening causes of chest pain like aortic dissection, PTX, PE, and ACS patients.
—/END/—
- Ranolazine is a selective inhibitor of the late Na+ channel. It affects myocardial metabolism.
- Medical Therapy vs. Revascularization
- A 70-year-old man presents with typical chest pain. You send him for a stress test. His treadmill stress test suggests coronary artery disease. The patient would prefer medical therapy over revascularization if possible. What medications should you put him on? See Medical therapy above.
- Note that there are more triage errors in women, minorities, elderly, diabetics, and pts dyspnea. Be careful with these pts.
- Thyroid disorder is a risk factor and cause of heart disease. Check and treat.
References / Further Reading
N Engl J Med. 2016 Jul 21;375(3):293. Chronic Stable Angina. https://www.ncbi.nlm.nih.gov/pubmed/27468079
Am Fam Physician. 2013 Oct 1;88(7):469-470. Diagnosis of Stable Ischemic Heart Disease: Recommendations from the ACP. http://www.aafp.org/afp/2013/1001/p469.html
Mieres JH, Gulati M, Bairey Merz N; American Heart Association Cardiac Imaging Committee of the Council on Clinical Cardiology; Cardiovascular Imaging and Intervention Committee of the Council on Cardiovascular Radiology and Intervention: Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: A consensus statement from the American Heart Association. Circulation 2014;130(4):350-379.” ABFM
Excellent article from the AAFP: http://www.aafp.org/afp/2013/1001/p469.html