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Source: Talbert RL. Ischemic Heart Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 27, 2012.

  • Angina pectoris
  • Coronary artery disease

  • Lack of oxygen and decreased or no blood flow to myocardium resulting from coronary artery narrowing or obstruction.

  • Coronary atherosclerosis
  • Coronary artery spasm
  • Coronary artery embolism or thrombosis

  • Transient episodes of myocardial ischemia occur because of imbalance between myocardial oxygen supply and demand that result from increased oxygen demand (determined by heart rate, ventricular contractility, and ventricular wall tension) or decreased oxygen supply (primarily determined by coronary blood flow).
  • Progressive decrease in vessel radius associated with coronary atherosclerosis impairs coronary blood flow and causes angina pectoris when myocardial oxygen demand increases, as with exertion.
  • Angina pectoris may occur because of abrupt reduction in blood flow due to coronary thrombosis (unstable angina) or localized vasospasm (variant or Prinzmetal angina) without increased oxygen demand.

  • Prevalence of angina pectoris ~1.5% for women and 4.3% for men aged 50–59 years.
  • Between 1980 and 2002, death rates due to coronary heart disease fell by 52% in men and 49% in women ages 65 years and older.

  • Age (55 years and older for men, 65 years and older for women)
  • Cigarette smoking
  • Diabetes mellitus
  • Dyslipidemia
  • Family history of premature cardiovascular disease
  • Hypertension
  • Chronic kidney disease
  • Obesity
  • Physical inactivity

Signs and Symptoms

  • Sensation of pressure or burning over sternum that may radiate to left jaw, shoulder, and arm.
  • Chest tightness and shortness of breath may occur and last from 30 seconds to 30 minutes.
  • Precipitating factors include:
    • Exercise
    • Cold environment
    • Walking after a meal
    • Emotional upset
    • Fright
    • Anger
    • Coitus
  • Relief occurs with rest and within 45 seconds to 5 minutes of taking nitroglycerin.
  • Variant (Prinzmetal) angina may be associated with pain at rest and in early morning hours.
  • Features of high-risk unstable angina include:
    • Accelerating tempo of ischemic symptoms in preceding 48 hours
    • Pain at rest lasting >20 minutes
    • Age older than 75 years
    • ST-segment changes
    • Clinical findings of pulmonary edema, mitral regurgitation, S3, crackles, hypotension, bradycardia, or tachycardia.
  • Episodes of ischemia may be silent in some patients.

Means of Confirmation and Diagnosis

  • Obtain medical history to determine:
    • Quality of chest pain
    • Precipitating factors
    • Duration
    • Pain radiation
    • Response to nitroglycerin or rest
  • Assess personal and family history of risk factors for coronary heart disease.
  • Cardiac examination may reveal:
    • Abnormal precordial systolic bulge
    • Decreased intensity of S1
    • Paradoxical splitting of S2
    • Presence of S3, or S4
    • Apical systolic murmur
    • Diastolic murmur

Laboratory Tests

  • Hemoglobin, fasting glucose, fasting lipoprotein panel.
  • Consider C-reactive protein and homocysteine level in select patients.
  • Cardiac enzymes are normal in stable angina; troponin T or I, myoglobin, and creatinine kinase myocardial band (CK-MB) may be elevated in unstable angina.

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