Key Points
- It is estimated that 1 in 3 adults in the United States (about 81 million) has some form of cardiovascular disease, including >17 million with ischemic heart disease and nearly 10 million with angina pectoris.
- Among persons 60-79 years of age, approximately 25% of men and 16% of women have ischemic heart disease, and these figures rise to 37% and 23% among men and women >80 years of age, respectively.
- Ischemic Heart Disease (IHD) is the number one cause of death in both men and women. It was responsible for nearly 380,000 deaths in the United States during 2010, with an age-adjusted mortality rate of 113 per 100,000 population.
- The total estimated cost for heart disease in the US in 2010 was $316 billion.
- Angina pectoris is the initial manifestation of IHD in approximately 50% of patients.
- Choices about diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, with the provider explaining information about risks, benefits, and costs to the patient. (I-C)
Diagnosis
Table 1. Clinical Classification of Chest Pain
| Typical angina (definite) | 1) Substernal chest discomfort with a characteristic quality and duration that is: 2) provoked by exertion or emotional stress and 3) relieved by rest or nitroglycerin |
| Atypical angina (probable) | Meets 2 of the above characteristics |
| Noncardiac chest pain | Meets 1 or none of the typical anginal characteristics |
Figure 1. Spectrum of Ischemic Heart Disease (IHD)
Table 2. Three Principal Presentations of Unstable Angina (UA)
TIMI Risk Score for UA/NSTEMI Calculator
| Rest angina | Angina occurring at rest and usually prolonged >20 min, occurring within 1 wk of presentation |
| New-onset angina | Angina of at least CCS Class III severity with onset within 2 mo of initial presentation |
| Increasing angina | Previously diagnosed angina that is distinctly more frequent, longer in duration, or lower in threshold (ie, increased by ≥1 CCS class within 2 mo of initial presentation to ≥CCS Class III severity) |
Class I – Angina only during strenuous or prolonged physical activity
Class II – Slight limitation, with angina only during vigorous physical activity
Class III – Symptoms with everyday living activities, ie, moderate limitation
Class IV – Inability to perform any activity without angina or angina at rest, ie, severe limitation
Table 3. Alternative Diagnoses to Angina for Patients with Chest Pain
| Nonischemic Cardiovascular | Pulmonary | Gastrointestinal | Chest Wall | Psychiatric |
|---|---|---|---|---|
| Aortic dissection | Pulmonary embolism | Esophageal Esophagitis Spasm Reflux | Costochondritis Fibrositis Rib fracture Sternoclavicular arthritis Herpes zoster (before the rash) | Anxiety disorders Hyperventilation Panic disorder Primary anxiety |
| Pericarditis | Pneumothorax Pneumonia Pleuritis | Biliary Colic Choledocholithiasis Cholangitis Peptic ulcer Pancreatitis | Affective disorders (ie, depression) Somatiform disorders Thought disorders (ie, fixed delusions) |
Table 4. Pretest Likelihood of Coronary Artery Disease (CAD) in Symptomatic Patients According to Age and Sexa
| Age, y | Nonanginal Chest Pain | Atypical Angina | Typical Angina | |||
|---|---|---|---|---|---|---|
| Men | Women | Men | Women | Men | Women | |
| 30-39 | 4 | 2 | 34 | 12 | 76 | 26 |
| 40-49 | 13 | 3 | 51 | 22 | 87 | 55 |
| 50-59 | 20 | 7 | 65 | 31 | 93 | 73 |
| 60-69 | 27 | 14 | 72 | 51 | 94 | 86 |
Adapted from Forrester and Diamond. N Engl J Med. 1979;300:1350-8.
Table 5. Comparing Pretest Likelihood of CAD in Low-Risk Symptomatic Patients With High-Risk Symptomatic Patients
| Age, y | Nonanginal Chest Pain | Atypical Angina | Typical Angina | |||
|---|---|---|---|---|---|---|
| Men | Women | Men | Women | Men | Women | |
| 35 | 3-35 | 1-19 | 8-59 | 2-39 | 30-88 | 10-78 |
| 45 | 9-47 | 2-22 | 21-70 | 5-43 | 51-92 | 20-79 |
| 55 | 23-59 | 4-21 | 45-79 | 10-47 | 80-95 | 38-82 |
| 65 | 49-69 | 9-29 | 71-86 | 20-51 | 93-97 | 56-84 |
Table 6. Medical Conditions Provoking or Exacerbating Ischemia
| Increased Oxygen Demand | Decreased Oxygen Supply |
|---|---|
| Noncardiac | Noncardiac |
| Hyperthermia | Anemia |
| Hyperthyroidism | Hypoxemia |
| Sympathomimetic toxicity (ie, cocaine use) | Pneumonia |
| Hypertension | Asthma |
| Anxiety | Chronic obstructive pulmonary disease |
| Arteriovenous fistulae | Pulmonary hypertension |
| Interstitial pulmonary fibrosis | |
| Obstructive sleep apnea | |
| Sickle cell disease | |
| Sympathomimetic toxicity (ie, cocaine use, pheochromocytoma) | |
| Hyperviscosity | |
| Polycythemia | |
| Leukemia | |
| Thrombocytosis | |
| Hypergammaglobulinemia | |
| Cardiac | Cardiac |
| Hypertrophic cardiomyopathy | Aortic stenosis |
| Aortic stenosis | Hypertrophic cardiomyopathy |
| Dilated cardiomyopathy | Significant coronary obstruction |
| Tachycardia | Microvascular disease |
| Ventricular | Congenital cardiac anomalies |
| Supraventricular | Shunts |
| Fistulae |
Figure 2. Diagnosis of Patients with Suspected Ischemic Heart Disease
Figure 3. Risk Assessment of Patients with Stable Ischemic Heart Disease (SIHD)
Figure 4. Guideline-Directed Medical Therapy for Patients with SIHD
Figure 5. Revascularization to Improve Survival of Patients with SIHD
Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain
- Patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD before additional testing. (I-C)
- Patients who present with acute angina should be categorized as stable or unstable. Patients with unstable angina (UA) should be further categorized as being at high, moderate, or low risk. (I-C)
- A resting electrocardiogram (ECG) is recommended in patients without an obvious, noncardiac cause of chest pain (I-B)
