Let's talk about one of the most important
and frightening diagnoses in primary care
and that's atherosclerotic cardiovascular disease.
We have a case here to help set up our discussion.
You can see, ouch, my chest.
The patient is a 54-year-old male with a six-hour
history of substernal chest pain which is constant.
It started after some heavy lifting
and radiates up to his left shoulder.
Oh-oh! Let’s see.
He’s otherwise asymptomatic.
He has a history of obesity and hypertension,
so a couple of cardiovascular risk factors there.
Plus, he’s a 54-year-old male.
That’s kind of in the sweet spot for
getting typical angina symptoms.
So, what's the most important exam to order
in the outpatient setting for this patient?
Is it, A, chest radiography;
B, an electrocardiogram;
C, a serum creatinine kinase with an MB fraction;
or D, serum troponin levels?
Now, the answer is B, electrocardiogram.
This is the first step in the evaluation of most patients
with chest pain beyond the history and physical examination.
But it does start with a history and physical.
And as the patient is describing
the history of chest pain to me,
I'm putting them in my mind
in terms of how it corresponds with typical
symptoms of angina and, therefore, their cardiac risk.
So, the type of pain with angina is usually a dull pressure.
So, that's a point against the patient unfortunately that
they may have cardiac disease with that dull pressure.
Whereas a sharp pain
or a more like lancinating pain like an electricity,
those aren't often associated with angina
or coronary artery disease and, therefore,
that’s something that makes me think,
oh good, this is not going to be coronary artery disease.
The duration of pain is important.
Most stable angina last for minutes and
then disappears oftentimes associated with activity.
Patients just say, yeah,
I get about two seconds.
It shoots through my chest and then it goes away.
Very unlikely angina.
And as well as a pain – yeah, it was there and it
stayed from Sunday all the way through Tuesday.
36 hours of pain.
Also probably not angina.
Of course, with the angina, it’s going
to be worse with physical activity,
straining, particularly Valsalva
where you’re really lifting
and pulling something hard.
patients who say, like, well, I rub some
cream on my chest and the pain goes away
or I give myself a massage,
I stretch out and it feels better,
that's probably more musculoskeletal obviously
than it would be angina and related to coronary artery disease.
Does the pain radiate anywhere?
So, typical sites of radiation
for angina include the shoulder,
the arms, the jaw and the neck,
that’s – and those are all concerning.
Sometimes with a musculoskeletal injury,
like a bad injury over the
lateral pectoral muscle,
the shoulder might be involved too,
but this is where it’s really kind of –
with angina, it’s actually traveling over there,
whereas in a musculoskeletal injury
it’s just going to be a general soreness in this area.
And associated symptoms.
Musculoskeletal pain doesn't promote nausea,
vomiting, numbness, tingling or diaphoresis.
And just to recall that musculoskeletal pain accounts
for most patients with chest pain who present to primary care,
Angina is actually pretty rare.
Also remember that there is a
difference between sexes on this issue.
So, stable angina and angina symptoms are much
more commonly encountered among men,
although women have a higher rate of
atherosclerotic cardiovascular disease overall.
And their disease among women is generally more deadly,
partly because they don’t have
typical symptoms that men have
that show that there is an incipient event coming.
So, women will just present –
they are more likely to present
with a myocardial infarction
as opposed to having stable angina
or something they could have done about it prior to it
becoming a critical situation where the heart has ischemia.
So, again, thinking back to the
history and risk stratification,
family history does count.
So, do take a family history of
other cardiovascular events.
Past medical history certainly counts.
Do they have some of the big diagnoses that are
known to promote a history of cardiac disease,
diabetes, hypertension, hyperlipidemia?
Are they smoking?
Are they obese?
And then looking at serum lipids is
probably the most important lab.
If I have to flip through something to evaluate,
okay, what is their risk stratification,
lipids are the one lab value I’d
hold on to more than any other.