History
- Age
- When did it start (cardiac cause – morning b/c of circadian rhythms), how did it start, what were you doing when it started
- How long did it last
- Type
- Location, radiation (neck, arm, back)
- Alleviating/aggravating (position – i.e. leaning forward in pericarditis)
- Travel, clots, pregnancy, cancer
- Risk factors (dyslipidemia, hypertension, diabetes, family history, smoking)
- Associated symptoms (nausea, palpitation, diaphoresis, presyncope, SOB, cough, fever, calf pain)
Exam
- Cardiac cause – ↑HR, ↑/↓BP, murmur
Immediate treatment
- #1 ASA 10mg chewed
- Morphine 5/10mg
- O2 NP 2L
- Nitro SL 0.3mg x 3 (5 minutes) – note: also relieves esophageal spasm
- IV NS (maintenance or ↓)
- Cardiac monitor
Investigations
- EKG → on admission and when pain free (dynamic changes on EKG)
- Troponin I → 6hr after onset of pain
- CK
- CBC – look for WBC
- Lytes – especially K+
- Creatinine
- Urea – dehydration
- Chest x-ray
Atypical presentation
- Women
- Elderly
- Diabetics
Unstable Angina
- Recent onset
- Progressive/crescendo
- Occurring ↑ frequency
- Less extertion
- More severe/prolonged pain
- Less response to nitros
- Pain at rest (lasting > 15 minutes)
Differential
- Cardiac:
- Angina (stable vs unstable)
- MI
- Pericarditis
- Endocarditis
- Dissection
- Prinzmetal’s (vasospasm – Tx CCB)
- Respiratory:
- Pneumoni
- Pneumothorax
- Pulmonary embolus
- MSK:
- Costochondritis
- Fractures
- GI
- GERD
- Peptic ulcer disease (PUD)
- Spasm, Achalasia, Nutcracker resophagus
- Gastritis
- Neurology
- Herpes zoster
- Neoplasm
- Psychiatry
- Panic attack
CCS classification for Angina
1 – only with strenuous, rapid or prolonged activity
2 – slightly limiting ordinary activity
3 – level walking at normal pace <1-2 blocks, <1 flight of stairs
4 – inability to carry on physical activity