Rita is a 57 year old Caucasian female with a complaint of chest discomfort for the past week
History elements/questions to be asked:
- Significant past medical history: hypertension, DM II, hyperlipidemia
- Past psychiatric history: anxiety, not on any medication. Hasn’t seen mental health professional since childhood
- Onset: 6 days ago, gradual onset (after taking a walk outside)
- Location: cannot point to one spot, general upper left side of her chest
- Duration: the pain is intermittent, on and off for past week. Generally lasts 2-5 min
- Character: pressure and tightness in chest, “feels like elephant sitting on chest” patient places clenched fist in center of chest to demonstrate.
- Alleviating: nitroglycerin, rest. Not alleviated with changing position or respiration
- Aggravating: pain is worse with exertion
- Radiating: to upper abdomen
- Timing: mostly mid-day, during activities
- Severity: worst is 6/10
- Associated symptoms: SOB, burning sensation in chest, nausea, sweating, lightheadedness, fatigue
- Previous episodes: none
- Recent illness: none
- Current medications: Losartan, Aspirin, Nitroglycerin sublingual PRN
- Previous cardiology consultation: patient denies seeing an outpatient cardiologist or having a stress test
- Social History: Admits previous history of smoking 1 pack a week for 10 years, quit 5 years ago. Denies history of drinking alcohol or illicit drug use. Diet of fast food, red meat, beans, rice, salad on occasion.
- Family history: Father died from MI at 45, grandmother had hypertrophic cardiomyopathy
- ROS:
- General – patient denies any current symptoms, not currently in discomfort denies fever and chills or night sweats.
- Head – Denies headaches, nausea, blurry vision
- Pulmonary –Denies wheezing, cough, dyspnea.
- Cardiovascular – Denies palpitations, current chest pain, edema/swelling of ankles or feet, syncope.
- Gastrointestinal –. Denies abdominal pain, constipation/diarrhea.
- Genitourinary – denies dysuria, hematuria, urgency/frequency,
- Nervous –Denies new left sided weakness, numbness and slurred speech.
- Musculoskeletal system – Denies muscle pain, stiffness, limp
Physical Exam
Vital Signs:
Blood Pressure: 111/71 (right arm, supine)
Heart Rate: 67 beats/minute (regular)
Respiration Rate: 18 breaths/minute (unlabored)
Temperature: 36.8 C (oral) O2 Sat: 98% (on room air)
Height: 5’ 4” cm Weight: 150 lbs BMI: 25.7
- General Appearance: 57-year-old casually-groomed female lying supine in hospital bed. No indications of acute distress, resting comfortably
- Neck: Supple, no JVD, thyroid nontender/not enlarged
- Chest: Normal breathing effort. Symmetrical, no deformities, no signs of trauma. Lateral: AP diameter 2:1. Non-tender to palpation.
- Lungs: Clear to auscultation bilaterally without rales, rhonchi, or wheezes, breathing unlabored and symmetrical.
- Cardiovascular: Regular rate and rhythm (RRR); S1 and S2 are normal. No S3, S4, splitting of heart sounds, friction rubs or other extra sounds, no precordial pulsation
- Abdomen: Soft, non-tender, non-distended, bowel sounds present
- Peripheral Vascular: Extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower, no LE edema. No stasis changes or ulcerations noted.
- Neurological: A&O X 3
Differential Diagnosis
1. Stable angina — this is a group of symptoms that consist of short attacks of anterior chest discomfort, usually precipitated by exertion. These attacks are due to temporary anoxia or ischemia of the myocardium which results when coronary circulation is inadequate for the needs of the myocardium at that time. This is generally due to coronary artery disease/arteriosclerosis. This patient has symptoms of chest discomfort only during exertion which resolves with rest. She also has a diet high in fat and hx of hypertension, DM II, hyperlipidemia and smoking (which are risk factors for heart disease) and family history of heart disease. Unstable angina is less likely for this patient, because in unstable angina the chest pain is less likely to follow a predictable pattern and may be experienced at rest
2. Acute coronary syndrome- an MI is an important differential to rule out when a patient comes in with chest pain and the symptoms can often be similar to angina. Checking cardiac enzymes and EKG is helpful for differentiating.
3. Pericarditis- This is often confused with angina, however in pericarditis the pain is more prolonged, and there will be signs of infection/inflammation such as fever. Pain would also be pleuritic, which increases with inspiration and when reclining and relieves with leaning forward. The patient will also likely report a history of recent illness. There may also be diffuse ST elevations on EKG and no elevation of cardiac enzymes.
4. Musculoskeletal pain/costochondritis- This is possible because the pain that the patient feels during exertion may be occurring when the patient is moving because the patient is engaging muscles that are sore or otherwise injured. However, chest wall pain is unlikely in this case because it would be more localized to a specific area of the chest and the pain would be reproducible by palpation. The patient will also likely have a history of recent heavy lifting or exercise.
5. Anxiety attack- The patient does have a history of anxiety, and has not seen a mental health professional since childhood. The symptoms of a panic attack can mimic an acute cardiac event or angina. This is lower on the differential list because of the patient’s extensive history of risk factors for arteriosclerosis.
Tests
- EKG: this is important for ruling out ACS and can help with diagnosing pericarditis. Because this patient is not currently experiencing an attack (no active ischemia), the EKG is likely to be normal, though it may indicate a previous infarction
- Labs such as CBC, CMP, lipid panel: This is important for risk stratification and for ruling out noncardiac causes of chest pain (anemia, infection, renal disease)
- Chest x-ray: This can be helpful in ruling out noncardiac explanations for chest pain such as pneumonia/infection, trauma, pneumothorax. Findings will usually be normal in patients with stable angina, but it may show cardiomegaly if the patient had a previous MI or pericardial effusion.
- CK-MB and cardiac troponins: within normal limits
- Coronary angiogram- this is the gold standard. Evidence of coronary stenosis of at least 70% is diagnostic of stable angina.
- Stress test: exercise treadmill test, pharmacologic and exercise echocardiography/ nuclear imaging can show areas of the heart with hypoperfusion during exertion
- Echocardiogram- This can show if the myocardium is damaged due to poor flow. A stress echo will probably be more useful because in stable angina the ischemic changes are not permanent and only present during times of decreased flow to the heart
- Cardiac CT/MRI- to evaluate coronary arteries for evaluation of CAD
- Urinalysis: wnl
Treatment Options
Medication Options:
- Nitrates: Nitroglycerin (sublingual) – 0.4mg under the tongue every 5 minutes up to 3 doses or isosorbide dinitrate/mononitrate. This will decrease myocardial oxygen demand through vasodilatation; they also will increase oxygen supply by reducing vasospasm and increasing coronary perfusion
- Beta blockers: Metoprolol – 100-400 mg in two divided doses orally or Atenolol – 50-200 mg daily. This will decrease myocardial oxygen demand by decreasing myocardial contractility and heart rate
- Calcium Channel Blockers: Amlodipine – 5-10 mg daily, Verapamil – 180-480 mg daily, Diltiazem – 180-360 mg divided in 3 or 4 doses daily. This will decrease myocardial oxygen demand by reducing blood pressure (i.e. decreasing wall tension), contractility, and heart rate; through vasodilatation, calcium channel blockers will also increase myocardial oxygen supply
- Selective late-current sodium inhibitor: Ranolazine 500-1000 mg twice daily, decreases late-phase inward sodium currents. Decreases the frequency of anginal episodes and improve functional capacity. Exact mechanism of action is incompletely understood
- HMG-COA reductase inhibitors: Simvastatin – 5-40 mg daily. This will lower MI rates and mortality for patients with established coronary artery disease through lipid-lowering and other pleiotropic mechanisms
- Aspirin – potent inhibitor of platelet aggregation; helps to prevent acute cardiac events in patients with chronic, stable angina
Monitoring
- Patient may be admitted to inpatient and placed on telemetry for further monitoring
Lifestyle
- heart healthy diet: fat/cholesterol restricted
Procedure
- Percutaneous Coronary Intervention – this includes percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting, and is useful for the reduction in anginal symptoms in patients refractory to medical therapy
Patient Counseling
Explain to the patient that the initial workup for an acute coronary syndrome— which includes a heart attack, was negative. She may now be admitted to the hospital so further imaging can be done to try to visualize the cause of her chest pain. While inpatient she will also be placed on telemetry so her heart can be monitored for any abnormal rhythms. She may need further testing and imaging studies. Most patients respond well to pharmacologic treatment, and have a decrease in the frequency and intensity of anginal episodes. If that does not work, she may need coronary revascularization, which should significantly reduce her symptoms and the need for antianginal medications.
When she is discharged, it is important that she follow up with an outpatient cardiologist and follow their recommendations. She should also be prepared for certain lifestyle changes, including reducing the cholesterol in her diet. If her symptoms become more severe or she has sudden onset of chest pain she should return immediately for ACS workup.
— Invite questions and use teach back to make sure that the patient has understood the important points after explaining.
https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.14.3.422
https://www.ncbi.nlm.nih.gov/books/NBK559016/
https://academic.oup.com/bmb/article/59/1/17/282054
https://www.mayoclinic.org/diseases-conditions/angina/diagnosis-treatment/drc-20369378
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