Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 187

Typical angina is characterized by three features:

1 Retrosternal or epigastric discomfort; neck/jaw/arm pain.

2 Occurrence with exertion or emotional stress.

3 Quick relief by rest or nitroglycerin (within 30 s – 5 min). A prolonged pain (>20 min), or a delay to relief with rest or nitroglycerin (>5 min) usually implies one of two extremes: acute MI or non-cardiac pain.

Angina is precipitated by walking uphill, in the cold, or after a meal.^* Nausea or diaphoresis during pain increases the likelihood of angina. Postprandial angina is often a marker of severe, sometimes multivessel CAD. As opposed to biliary colic or peptic ulcer disease, angina occurs immediately after the meal and is exacerbated by postprandial physical activity. Nocturnal angina may imply severe CAD vs. vasospasm on top of fixed CAD; the increased venous return in the recumbent position increases O₂ demands and triggers ischemia in patients with critical, sometimes multivessel, CAD. Rest angina without an exertional component may be seen in patients with significant CAD whose angina is mainly triggered by a vasospastic reduction of O₂ supply (although many of the latter patients also have exertional angina). Dyspnea may be an angina equivalent and may indicate extensive CAD with secondary increase in LVEDP during ischemic spells; however, dyspnea is very non-specific compared to chest pain. “Warm-up” angina is angina that starts with the onset of activity and improves with further exertion (e.g., in the morning); it suggests a very severe stenosis, with collaterals that get recruited during exertion and a myocardium that adapts to ischemia (ischemic preconditioning).

Figure 3.1 Clinical probability of CAD.

* Combination of diabetes, smoking, or hyperlipidemia (LDL >160–190 mg/dl), especially when all three are present.¹⁷