Angina Pectoris – Top USMLE Diseases

Acute coronary syndrome (ACS) encompasses conditions that include confirmed or suspected myocardial ischemia or myocardial infarction (MI). ACS, which includes non-ST-elevation MI (NSTEMI), ST-elevation MI (STEMI), and unstable angina, usually results from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Patients most commonly present with chest pain but also may have atypical symptoms. Diagnosis is by clinical history, ECG changes, elevated cardiac enzymes (preferably, high-sensitivity cardiac troponin), and/or evidence of wall motion abnormalities on imaging. Both STEMI and NSTEMI have loss of myocardial tissue, but STEMI is due to transmural ischemia (indicating complete major coronary artery obstruction). NSTEMI occurs because of subendocardial ischemia (indicating partial major coronary artery obstruction). Unstable angina occurs when ischemia does not result in infarction (no troponin elevation and typically with non-ST-elevation changes on ECG). Management of STEMI depends on the timing of the presentation and local resources with regard to thrombolytic therapy versus percutaneous intervention. Both unstable angina and NSTEMI are managed the same way, with both conservative (medical) and invasive strategies available. Additionally, routine medical therapy includes dual antiplatelet therapy, nitrates, oxygen, pain control, and beta-blockers.

Vasospastic angina, also known as Prinzmetal or variant angina, is an uncommon cause of chest pain due to transient coronary artery spasms. The pathophysiology is distinguished from stable or unstable angina secondary to atherosclerotic coronary artery disease (CAD). Clinical presentation is characterized by spontaneous episodes of chest pain from a transient decrease in blood flow to the epicardial arteries. Diagnosis is made by clinical history, normal exam, and ECG findings of ST-segment changes during an episode. Cardiac enzymes and angiography are usually normal. Management includes the prevention of vasospasm with calcium channel blockers and the relief of angina with nitrates.

Angina pectoris (or angina), which presents as chest pain due to transient myocardial ischemia, is considered an important symptom of coronary heart disease (CHD). This symptom, along with risk factors for atherosclerosis, indicates the increased probability of having ischemic heart disease. Clinically, stable angina is chest pain occurring with activity and/or emotional stress and is predictably relieved by rest and/or nitroglycerin. Diagnosis is by history and examination, ECG, and stress testing, with the possible addition of nuclear medicine imaging, echocardiography, or coronary angiography. Management with lifestyle modifications and aggressive risk factor reduction (e.g., optimal management of hypertension, diabetes, and hyperlipidemia) is indicated to prevent the risk of progression to MI and death.

The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels including the superior vena cava, inferior vena cava, pulmonary arteries, pulmonary veins, and aorta. The mediastinum extends from the upper thoracic aperture to the diaphragm and is bordered by the lungs.

The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Blood flows through the heart in 1 direction, moving from the right side of the heart, through the lungs, and then returning to the left side of the heart, where it is pumped out to the rest of the body. As blood moves through the heart, 4 important valves prevent backflow. The heart muscle itself is supplied by the coronary arteries. The heart also has its own conduction system, triggering its own rhythmic contractions.

Subclavian steal syndrome occurs when narrowing/occlusion of the subclavian artery proximal to the origin of the vertebral artery causes a reversal of blood flow in the ipsilateral vertebral artery to continue perfusing the ipsilateral arm. The most common cause is atherosclerosis. Symptoms are rare, but when they occur are usually triggered by physical exertion of the arm and subsequent hypoperfusion of the arm or brain. Patients may present with claudication, pain, pallor, paresthesias, and weakened pulse in the affected extremity. Patients may also present with transient neurologic disturbances concerning for a stroke. Diagnosis is made by clinical findings and imaging (ultrasound, CT, MRI). In addition to appropriate management of atherosclerosis, symptomatic patients may need angioplasty/stenting or surgical revascularization.

Vasospastic angina, also known as Prinzmetal or variant angina, is an uncommon cause of chest pain due to transient coronary artery spasms. The pathophysiology is distinguished from stable or unstable angina secondary to atherosclerotic coronary artery disease (CAD). Clinical presentation is characterized by spontaneous episodes of chest pain from a transient decrease in blood flow to the epicardial arteries. Diagnosis is made by clinical history, normal exam, and ECG findings of ST-segment changes during an episode. Cardiac enzymes and angiography are usually normal. Management includes the prevention of vasospasm with calcium channel blockers and the relief of angina with nitrates.

An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Electrocardiograms are simple, inexpensive, noninvasive, and readily obtained. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. In the healthy state, an ECG records predictable, reproducible waves and complexes, which correspond to electromechanically coupled physiologic events in the heart. Under pathologic conditions, the ECG can detect arrhythmias, ischemia, inflammation, and more.

Stable and unstable angina are considered an important symptom of coronary heart disease (CHD) and present with chest pain due to transient myocardial ischemia. These disorders can be a warning sign for the risk of heart attack (MI) in the future. Clinically, stable and unstable angina are differentiated by exacerbating factors, duration of symptoms, and response to rest and medications. Diagnosis is by history and examination, ECG, stress testing with possible additional nuclear medicine imaging, echocardiography, or coronary angiography. Management with lifestyle modifications and aggressive risk factor reduction (of hypertension, diabetes, and hyperlipidemia) is indicated to prevent the risk of progression to MI and death.

MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Diagnosis is by clinical history, ECG changes, an increase in cardiac enzymes, and evidence of wall motion abnormalities on imaging. Management depends on the timing of the presentation and local resources with regard to thrombolytic therapy versus percutaneous intervention. All patients receive nitrates, pain control, aspirin, anticoagulation, and beta-blockers (unless contraindicated).

Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. The myocardium becomes ischemic when oxygen supply does not meet oxygen demand. Diagnosis is based on history and ECG findings; cardiac stress tests and catheterizations may also be needed. Treatment is primarily based on reducing the heart's oxygen demand and increasing the delivery of oxygen.