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(/* ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT){{cite journal| author=Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al.| title=ACC/AHA/ACP-ASIM guidelines for the managemen...)
 
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{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
 
{{CMG}}, '''Associate Editor-in-Chief:''' [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan, M.B.B.S.]]


==Overview==
==Overview==
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the [[epigastrium]] (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina.  Angina is considered to be stable when it remains reasonably constant and predictable in terms of severity, presentation, character, precipitants, and response to therapy.  Symptoms as progressively worsening angina (accelerated angina), one or more episodes of angina at rest, or a new-onset angina classified as [[unstable angina]].
The name 'angina pain' can be thought of as a misnomer as patients often describes the sensation as discomfort rather than physical pain. The best method to characterize this discomfort/pain is through the 'PQRST system'.


==Type and quality of the pain==
==History and Symptoms==
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the [[epigastrium]] (upper central abdomen), back, neck, jaw, or shoulders.Pain or discomfort often described as tight, dull or heaviness at chest.  Some patients have difficulty to describing the discomfort or deny that their discomfort is a true pain at all.
===Provocation/Palliation (P)===
* The most common cause of anginal pain is exertion.  Anginal discomfort is often relieved by rest or [[nitroglycerine]]. Usually relief from rest or nitroglycerine occurs in 2 to 3 minutes.
* Less common precipitants of anginal discomfort include:
:*Emotional distress
:* A large meal
:* Cold weather
:* Cocaine
:*[[Anemia]]
:*[[Thyrotoxicosis]]
* The discomfort is not precipitated by changes in position. This is in contrast to [[pericarditis]] which is relieved by sitting up or sitting forward.
* In following the patient with chronic stable angina, the duration and or distance of exertion required to provoke the angina should be recorded to monitor the response to therapy.


==Location of the pain==
Stable angina can be classified basing upon features.
The pain is often retrosternal or left side of chest and can radiate to left arm, neck, jaw and back. The most frequent initial location of angina is in the central chest and the retrosternal area, but the left pectoral region, arms and hands, root of the neck, epigastrium, and even the right side of the chest may be initial sites. Quite frequently, the pain starts in one of the other areas and later on spreads to the central chest. Occasionally, patients may complain of only interscapular or left infrascapular back pain. Discomfort that is located below the umbilicus or above the mandible is unlikely to be angina.
* Substernal [[chest pain]].
* Pain provocated by exertion and/or emotional stress.
* Relieved with rest and/or [[nitroglycerin]].


==Radiation of the pain==
Typical angina - All the three features.
Typical locations for radiation of the pain are the arms (often inner left arm), shoulders, and neck into the jaw.
Atypical angina - two features.
Non-anginal chest pain - one feature.


==Severity of the pain==
===Quality/Quantity (Q)===
During the initial evaluation of patients with suspected or established angina, it is desirable to assess its severity as a guide to therapy.  A number of methods have been proposed to assess function impairment by history, based on the degree of physical activity that precipitates angina. The New York Heart Association (NYHA) functional classification has largely been replaced by the Canadian Cardiovascular Society (CCS) functional classifications or by classification systems based on the activity levels that can be related to the metabolic equivalents during treadmill exercise tests (A Specific Activity Scale developed by Goldman and colleagues and the angina score by Califf and colleagues). It should be noted that any functional classification is subject to variability in activity tolerance as perceived by patients and hence its reproducibility is variable.  
* The nature of the sensation is usually not described as a "pain" but rather as a discomfort.  It is often described as:
:* A sense of heaviness
:* Squeezing
:* Pressure
:* Choking
:* Strangling
:* Band like tightness
:* Or even as an "elephant sitting on my chest"
* The pain is not sharp or [[pleuritic]] in nature. This is in contrast [[pericarditis]] which is described in this way.


After an episode of severe, [[transient ischemia]], the [[myocardium]] may be temporarily stunned, which means that it remains transiently dysfunctional after the ischemia has resolved. When a part of the myocardium is chronically hypoperfused, it may not show evidence of ischemia on the electrocardiogram but may still be dysfunctional or even akinetic. It is important to distinguish this reversible clinical entity (so called hibernating myocardium) from myocardium that is dysfunctional secondary to irreversible infarction, because hibernating myocardium may regain normal function when perfusion is restored.
===Region/Radiation (R)===
* Typically the angina is located in the center of the chest or on the left side of the chest. 
* Less frequently the discomfort is predominantly in the [[epigastrum]], the shoulders, neck or jaw.
* In some patients, the pain may radiate to the inner aspect of the left arm, the neck or the jaw.  


==Relation to exertion==
===Severity Scale (S)===
Angina is often brought on with exertion or emotional stress and in majority of cases eased with rest. Exertion induced angina ([[exertional angina]]), which is the most common clinical presentation of patients with stable angina, is precipitated by an increase in myocardial oxygen demand above myocardial oxygen supply. In some patients, however, myocardial ischemia is partially or totally secondary to a spontaneous reduction in coronary blood flow.
* The patient should be asked to rank their pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever.
* The patient should be asked:
:* Does the discomfort interferes with activities?
:* How bad the discomfort is when it is at its worst?
:* Does it force the patient to sit down, lie down, or slow down?
* Both the [[ New york heart association functional classification|New York Heart Association functional classification scheme]] (NYHA) and the [[Canadian Cardiovascular Society Classifications of Angina Pectoris|Canadian Cardiovascular Society functional classification]] (CCS) can be used to quantify the severity of anginal pain.


==Duration of the pain==
===Timing (T)===
Typically angina pectoris symptoms last up to several minutes after exertion or emotional stress has stopped. The duration of angina pectoris is variable but it usually lasts 2 to 5 minutes. It is uncommon for the episodes of stable angina pectoris to be either very brief (<60 sec), or prolonged (>30 min).  Anginal pain provoked by emotion may be relieved more slowly than that provoked by physical exercise.
* Anginal discomfort usually lasts 1 to 5 minutes with a range from 1 minute to 30 minutes.  Pain that lasts seconds is usually not anginal pain.
* The pain is usually relieved in 2 to 3 minutes with rest or nitroglycerine. Anginal discomfort associated with emotional distress is usually relieved more slowly.
* Angina that occurs at night ([[Nocturnal angina pectoris|nocturnal angina]]) is characteristic of [[Coronary Vasospasm|coronary spasm]].
* In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy.


==Precipitating factors==
===Associated Symptoms===
Precipitating factors include emotions (anger, excitation, fear and frustration), cold weather, a heavy meal and cocaine use. Exertional angina or classic angina is characteristically induced by physical activity and is often precipitated more easily in cold weather or after eating a heavy meal (fatty and/or spicy meal).  
*There may be symptoms of systolic or diastolic left ventricular dysfunction that leads to shortness or breath or [[dyspnea]]. 
*In some patients, chest discomfort is not present, and [[dyspnea]] is the anginal equivalent.


Some patients, experience angina pectoris more frequently in the early morning than during the remainder of the day despite less or no physical activity at this time. Exercising the upper extremities above the head precipitates angina more readily than exercising the lower extremities.
<center>
==Classifications of Functional Capacity and Severity in Chronic Stable Angina==


In some patients [[dyspnea]] may reflect myocardial ischemia and left ventricular dysfunction and may be termed an "anginal equivalent". Both ischemic cardiac discomfort and cardiac dyspnea are worse during physical activity than at rest, and if activity relieves the symptoms, then it is unlikely that the symptoms are related to myocardial ischemia.
{| border="1" align="center" style="background:lightskyblue"
|-
|  bgcolor="CornFlowerBlue" |'''Class'''
|  bgcolor="CornFlowerBlue" |'''[[NYHA classification|New York Heart Association Classification]]'''
|  bgcolor="CornFlowerBlue" |'''[[CCS classification|Canadian Cardiovascular Society Classification]]'''
|-
| '''Class I'''
|'''No limitation:'''
*Heart disease exists with no symptoms or limitation of physical activity.  


==Relieving factors==
*Ordinary physical activity does not cause [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]] that limit activity.
The impact of rest, discontinuation of the activity and nitroglycerin administration should be evaluated.  The relief of angina usually occurs within several minutes after cessation of exertion (it may last up to 10 minutes or even longer after very strenuous exercise). Prompt relief is also achieved with administration of sublingual nitroglycerin. The hemodynamic effects of sublingual [[nitroglycerin]] usually begin within a minute, and the stable angina is generally relieved within 2 or 3 minutes. Chest discomfort that is instantaneously relieved by nitroglycerin is less likely to be angina pectoris.
|
*Ordinary physical activity does not cause angina, such as walking, climbing stairs.
*Angina occurs with strenuous, rapid or prolonged exertion at work or recreation.
|-
| '''Class II'''
| '''Minimal limitation:'''
*There is slight limitation of physical activity.
   
*Comfortable at rest, but ordinary physical activity results in [[Chronic stable angina|angina]], [[fatigue]], [[palpitation]], or [[dyspnea]].
|
*Slightly limited ordinary physical activities.
*Angina occurs on:
:*walking or climbing stairs rapidly,
:*walking uphill, walking or stair climbing after meals, or in cold, or in wind, or
:*under emotional stress, or  
:*only during the few hours after awakening.  
*Walking more than two blocks on the same level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
|-
| '''Class III'''
| '''Marked limitation:'''
*Patients have marked limitation of physical activity.
*Comfortable at rest, but less than ordinary activity, such as walking 20–100 m, causes [[fatigue]], [[palpitation]], or [[dyspnea]].
|
*Marked limitations of ordinary physical activity.
*Angina occurs on walking one to two blocks (equivalent to 100-200m) on the same level and climbing one flight of stairs at a normal pace under normal conditions.
|-
| '''Class IV'''
| '''Extreme limitation:'''
*Severe limitation; unable to carry out any physical activity without discomfort.
*[[chronic stable angina|Angina]] and/or symptoms of cardiac insufficiency may be present at rest.  
*If any physical activity is undertaken, discomfort is increased.
*Usually self-confined to bed or a chair.
|
*Inability to carry on any physical activity without any discomfort.
*Angina occurs at rest.
|}</center>


==ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==
{{cquote|
===Class I===
'''1.''' In patients presenting with [[chest pain]], a detailed symptom history, focused physical examination, and directed [[Chronic stable angina risk stratification exercise testing|risk factor assessment]] should be performed. With this information, the clinician should estimate the probability of significant [[CAD]] (ie, low, intermediate, high). ''(Level of Evidence: B)''}}


==ESC Guidelines- Clinical Evaluation and ECG for Risk Stratification (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 }} </ref>==
===Clinical Evaluation of Patients With Chest Pain (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210 }} </ref>===
{{cquote|
'''Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain'''
===Class I===
'''1.''' Detailed clinical history and physical examination including BMI and/or waist circumference in all patients, also including a full description of symptoms, quantification of functional impairment, past medical history, and cardiovascular risk profile. ''(Level of Evidence: B)''


'''2.''' Resting [[ECG]] in all patients. ''(Level of Evidence: B)''}}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


==See Also==
|-
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''1.''' Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional
testing.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>


==Sources==
|-
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= |url=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
| bgcolor="LightGreen"|
<nowiki>"</nowiki>'''2.''' Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as
being at high, moderate, or low risk.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>
|}


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
==ESC Guidelines- Clinical Evaluation (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==


*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Detailed clinical history and [[physical examination]] including [[BMI]] and/or waist circumference in all patients, also including a full description of symptoms, quantification of functional impairment, past medical history, and [[Coronary risk profile (patient information)|cardiovascular risk profile]]. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina electrocardiography|Resting ECG]] in all patients. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
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Latest revision as of 17:15, 28 October 2016

Chronic stable angina Microchapters

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Chronic Stable Angina
Atypical
Walk through Angina
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

The name 'angina pain' can be thought of as a misnomer as patients often describes the sensation as discomfort rather than physical pain. The best method to characterize this discomfort/pain is through the 'PQRST system'.

History and Symptoms

Provocation/Palliation (P)

  • The most common cause of anginal pain is exertion. Anginal discomfort is often relieved by rest or nitroglycerine. Usually relief from rest or nitroglycerine occurs in 2 to 3 minutes.
  • Less common precipitants of anginal discomfort include:
  • The discomfort is not precipitated by changes in position. This is in contrast to pericarditis which is relieved by sitting up or sitting forward.
  • In following the patient with chronic stable angina, the duration and or distance of exertion required to provoke the angina should be recorded to monitor the response to therapy.

Stable angina can be classified basing upon features.

  • Substernal chest pain.
  • Pain provocated by exertion and/or emotional stress.
  • Relieved with rest and/or nitroglycerin.

Typical angina - All the three features. Atypical angina - two features. Non-anginal chest pain - one feature.

Quality/Quantity (Q)

  • The nature of the sensation is usually not described as a "pain" but rather as a discomfort. It is often described as:
  • A sense of heaviness
  • Squeezing
  • Pressure
  • Choking
  • Strangling
  • Band like tightness
  • Or even as an "elephant sitting on my chest"
  • The pain is not sharp or pleuritic in nature. This is in contrast pericarditis which is described in this way.

Region/Radiation (R)

  • Typically the angina is located in the center of the chest or on the left side of the chest.
  • Less frequently the discomfort is predominantly in the epigastrum, the shoulders, neck or jaw.
  • In some patients, the pain may radiate to the inner aspect of the left arm, the neck or the jaw.

Severity Scale (S)

  • The patient should be asked to rank their pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever.
  • The patient should be asked:
  • Does the discomfort interferes with activities?
  • How bad the discomfort is when it is at its worst?
  • Does it force the patient to sit down, lie down, or slow down?

Timing (T)

  • Anginal discomfort usually lasts 1 to 5 minutes with a range from 1 minute to 30 minutes. Pain that lasts seconds is usually not anginal pain.
  • The pain is usually relieved in 2 to 3 minutes with rest or nitroglycerine. Anginal discomfort associated with emotional distress is usually relieved more slowly.
  • Angina that occurs at night (nocturnal angina) is characteristic of coronary spasm.
  • In following the patient with angina, the frequency and duration of pain, should be recorded to assess the response to therapy.

Associated Symptoms

  • There may be symptoms of systolic or diastolic left ventricular dysfunction that leads to shortness or breath or dyspnea.
  • In some patients, chest discomfort is not present, and dyspnea is the anginal equivalent.

Classifications of Functional Capacity and Severity in Chronic Stable Angina

Class New York Heart Association Classification Canadian Cardiovascular Society Classification
Class I No limitation:
  • Heart disease exists with no symptoms or limitation of physical activity.
  • Ordinary physical activity does not cause angina, such as walking, climbing stairs.
  • Angina occurs with strenuous, rapid or prolonged exertion at work or recreation.
Class II Minimal limitation:
  • There is slight limitation of physical activity.
  • Slightly limited ordinary physical activities.
  • Angina occurs on:
  • walking or climbing stairs rapidly,
  • walking uphill, walking or stair climbing after meals, or in cold, or in wind, or
  • under emotional stress, or
  • only during the few hours after awakening.
  • Walking more than two blocks on the same level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
Class III Marked limitation:
  • Patients have marked limitation of physical activity.
  • Comfortable at rest, but less than ordinary activity, such as walking 20–100 m, causes fatigue, palpitation, or dyspnea.
  • Marked limitations of ordinary physical activity.
  • Angina occurs on walking one to two blocks (equivalent to 100-200m) on the same level and climbing one flight of stairs at a normal pace under normal conditions.
Class IV Extreme limitation:
  • Severe limitation; unable to carry out any physical activity without discomfort.
  • Angina and/or symptoms of cardiac insufficiency may be present at rest.
  • If any physical activity is undertaken, discomfort is increased.
  • Usually self-confined to bed or a chair.
  • Inability to carry on any physical activity without any discomfort.
  • Angina occurs at rest.

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1]

Clinical Evaluation of Patients With Chest Pain (DO NOT EDIT)[1]

Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain

Class I

"1. Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional testing.(Level of Evidence:C)"

"2. Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as being at high, moderate, or low risk.(Level of Evidence:C)"

ESC Guidelines- Clinical Evaluation (DO NOT EDIT)[2]

Class I
"1. Detailed clinical history and physical examination including BMI and/or waist circumference in all patients, also including a full description of symptoms, quantification of functional impairment, past medical history, and cardiovascular risk profile. (Level of Evidence: B)"
"2. Resting ECG in all patients. (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  2. ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.


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