Chronic stable angina physical examination: Difference between revisions

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(/* ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT){{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...)
 
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{{WikiDoc Cardiology Network Infobox}}
{{Chronic stable angina}}
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{{EH}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}


==Overview==
==Overview==
-------------------------------------------------------------------------------------------------------------------------------------
Among patients with chronic stable angina, the physical examination may be asymptomatic or characteristically normal. Patients that present with left ventricular dysfunction are associated with a poorer prognosis than patients who do not present with dysfunction. All patients should be examined carefully for the presence of [[rales]] and other signs of [[heart failure]]. The majority of patients present with history of either, chest pain or discomfort categorized as: typical or atypical. Typical presentation would include pain or discomfort in the front or anterior precordium. Atypical presentation can be more convoluted in presentation and involve a wide range of symptoms. For example, an atypical patient may present with [[dyspnea]] instead of chest pain and this is termed an angina equivalent. In addition to the historical presentation of chest pain or discomfort, the patient history should be extensively evaluated to include an assessment of cardiovascular risk factors. Physical examination may be normal or asymptomatic. In some cases, a physical examination may reveal [[heart failure]]. Additional findings can be important in understanding the onset of the condition. For instance, the presence of [[peripheral vascular disease]] may be associated with an increased risk of [[coronary artery disease| coronary artery disease (CAD)]].


A good history and physical examination is the key to diagnosis. If the history is suggestive of angina, it is desirable to assess its severity to help guide further diagnostic studies and treatment. The [[New York Heart Association]] functional classification has been largely replaced by the [[Canadian Cardiovascular Society]] functional classification. Physical examination may be normal but helps in forming a [[differential diagnosis of chest pain]]
==Physical Examination==
* The physical examination may be entirely normal in patients with stable angina pectoris.
* A patient may present with [[hypertension]], a major risk factor for coronary artery disease.
* Examination of the cardiovascular system during ischemia, however, may reveal:
:* Elevated blood pressure
:* Transient third heart sound ([[S3]] - ventricular filling sound) and fourth heart sound ([[S4]] - atrial filling sound)
:* A sustained outward (dyskinetic) systolic movement of the left ventricular apex
:* A murmur of [[mitral regurgitation]]
:* Paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave
* The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular [[aortic stenosis]], cardiomyopathy and [[pulmonary hypertension]]).
* Cardiovascular assessment should also include:
:* Examination of peripheral arterial pulses
:* Evaluation of retinal fundus for vascular changes
:* Screening for risk factors of coronary artery disease (CAD)
:* Stigmata of genetic dyslipidemia syndromes such as:
::* Tendon xanthomas
::* [[Xanthelasma]]
::* Corneal arcus, particularly in patients under 50 years of age
* Since the presence of non-coronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination should include attention to:
:* Peripheral arterial pulses
:* Auscultation of the carotid arteries for bruits
:* Palpation of the abdomen for aneurysm


==Clinical Evaluation of Angina Pectoris==
==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>==
-------------------------------------------------------------------------------------------------------------------------------------


===History===
===History and Physical (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>===
Clinical evaluation of angina should always start by obtaining a good history. Classic angina is angina associated with exercise or emotional stress and relieved by rest or [[nitroglycerin]]. However, it should be noted that in some patients, [[dyspnea]], not chest discomfort, with exercise or stress may be the presentation of angina and is termed as ''angina equivalent''. If the history is suggestive of angina, its severity should be assessed based on the [[Canadian Cardiovascular Society Functional Classification]]


During initial evaluation of the patient with possible angina, the physician should also determine whether risk factors for atherosclerotic coronary artery disease ([[hyperlipidemia]], [[diabetes mellitus]], [[hypertension]], [[cigarette smoking]], [[obesity]] and a family history of premature [[coronary artery disease]]) are present, since these risk factors not only increase the likelihood that the patient has underlying coronary disease but also serve as potential targets for intervention.  
===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>===
'''Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain'''


In women, the menstrual status as well as [[hormone replacement therapy]] (HRT) should be assessed, since the risk of coronary artery disease (CAD) rises in postmenopausal women who are not receiving estrogen (or estrogen / progesterone combinations) replacement therapy. Inquiries should be made for a history of peripheral vascular disease, or symptoms thereof, such as leg circulation and transient ischemic attacks, because the prevalence of CAD is substantially higher in patients with peripheral vascular disease, carotid artery disease and thoraco-abdominal aortic aneurysms.
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


As mentioned earlier in pathophsiology section, although coronary artery disease (CAD) is, by far, the most frequent cause of angina pectoris, in the absence of atherosclerotic obstructive coronary artery disease (CAD), typical angina can be a symptom of [[hypertrophic cardiomyopathy]], ischemic or non-ischemic [[dilated cardiomyopathy]], [[restrictive cardiomyopathy]] and [[pulmonary artery hypertension]].
|-
| 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>


Clinical evaluation and appropriate investigations establish the diagnosis in such patients. According to risk factor management strategy, the summary of risk factors for coronary artery disease as follow;
|-
 
| bgcolor="LightGreen"|
*Non-modifiable risk factors
<nowiki>"</nowiki>'''2.''' Patients who present with acute angina should be categorized as stable or unstable; patients with UA should be further categorized as
**Age (more frequently in elderly)
being at high, moderate, or low risk.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>
**Gender; more in male gender. Post menopausal women have almost equal risk for coronary artery disease.
|}
**Family history of premature coronary artery disease
 
*Modifiable risk factors
**Cigarette smoking
**Abnormal lipid levels (high LDL, low HDL cholesterol)
**Diabetes mellitus
**Sedentary lifestyle
**Hypertension (especially uncontrolled hypertension)
**Cerebrovascular disease
**Peripheral vascular disease
**Obesity
 
 
===Physical examination===
 
The physical examination may be entirely normal in patients with stable angina pectoris, although hypertension, a major risk factor for coronary artery disease (CAD) may be present.
 
Examination of the cardiovascular system during ischemia, however, may reveal elevated blood pressure, transient third heart sound (S3 - ventricular filling sound) and fourth heart sound (S4 - atrial filling sound), a sustained outward (dyskinetic) systolic movement of the left ventricular apex, a murmur of mitral regurgitation, and paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave.
 
The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular aortic stenosis, cardiomyopathy and pulmonary hypertension).
 
Cardiovascular assessment should also include the examination of peripheral arterial pulses, evaluation of retinal fundus for vascular changes and screening for risk factors of coronary artery disease (CAD), stigmata of genetic dyslipidemia syndromes such as tendon xanthomas, xanthelasma, and corneal arcus, particularly in patients under 50 years of age.
 
Since the presence of noncoronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination of peripheral arterial pulses, auscultation of the carotid arteries for bruits and palpation of the abdomen for aneurysm are important in clinical evaluation.
 
==ACC / AHA Guidelines- History and Physical (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. 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. 1999; 99: 2829–2848. PMID 10351980</ref>==
{{cquote|
===Class I===
1. In patients presenting with [[chest pain]], a detailed symptom history, focused [[physical examination]], and directed 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)''}}
 
 
{{Circulatory system pathology}}
{{SIB}}
[[Category:Cardiology]]


==References==
{{reflist|2}}
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[[Category:Up-To-Date cardiology]]

Latest revision as of 17:18, 28 October 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Among patients with chronic stable angina, the physical examination may be asymptomatic or characteristically normal. Patients that present with left ventricular dysfunction are associated with a poorer prognosis than patients who do not present with dysfunction. All patients should be examined carefully for the presence of rales and other signs of heart failure. The majority of patients present with history of either, chest pain or discomfort categorized as: typical or atypical. Typical presentation would include pain or discomfort in the front or anterior precordium. Atypical presentation can be more convoluted in presentation and involve a wide range of symptoms. For example, an atypical patient may present with dyspnea instead of chest pain and this is termed an angina equivalent. In addition to the historical presentation of chest pain or discomfort, the patient history should be extensively evaluated to include an assessment of cardiovascular risk factors. Physical examination may be normal or asymptomatic. In some cases, a physical examination may reveal heart failure. Additional findings can be important in understanding the onset of the condition. For instance, the presence of peripheral vascular disease may be associated with an increased risk of coronary artery disease (CAD).

Physical Examination

  • The physical examination may be entirely normal in patients with stable angina pectoris.
  • A patient may present with hypertension, a major risk factor for coronary artery disease.
  • Examination of the cardiovascular system during ischemia, however, may reveal:
  • Elevated blood pressure
  • Transient third heart sound (S3 - ventricular filling sound) and fourth heart sound (S4 - atrial filling sound)
  • A sustained outward (dyskinetic) systolic movement of the left ventricular apex
  • A murmur of mitral regurgitation
  • Paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave
  • The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular aortic stenosis, cardiomyopathy and pulmonary hypertension).
  • Cardiovascular assessment should also include:
  • Examination of peripheral arterial pulses
  • Evaluation of retinal fundus for vascular changes
  • Screening for risk factors of coronary artery disease (CAD)
  • Stigmata of genetic dyslipidemia syndromes such as:
  • Tendon xanthomas
  • Xanthelasma
  • Corneal arcus, particularly in patients under 50 years of age
  • Since the presence of non-coronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination should include attention to:
  • Peripheral arterial pulses
  • Auscultation of the carotid arteries for bruits
  • Palpation of the abdomen for aneurysm

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

History and Physical (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)"

References

  1. ↑ 1.0 1.1 1.2 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.

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