Angina Diagnosis

Aka: Angina Diagnosis, Chest Pain Risk of Angina

1. See Also
   1. Chest Pain
   2. Acute Coronary Syndrome
   3. Acute Coronary Syndrome Immediate Management
2. Indications
   1. Likelihood of Angina as cause for Chest Pain
3. Differential Diagnosis
   1. See Chest Pain
   2. See Chest Pain Causes
4. Determining Cardiac Chest Pain
   1. Criteria
      1. Substernal Chest Pain
      2. Exertional Chest Pain
      3. Chest Pain relieved with rest
   2. Interpretation
      1. Typical Angina: 3 criteria from above
         1. Age 30-39: 76% likelihood (intermediate) in men and 26% in women (intermediate)
         2. Age 40-49: 87% likelihood (high) in men and 55% in women (intermediate)
         3. Age 50-59: 93% likelihood (high) in men and 73% in women (intermediate)
         4. Age 60-69: 94% likelihood (high) in men and 86% in women (high)
      2. Atypical Angina: 2 criteria from above
         1. Age 30-39: 34% likelihood (intermediate) in men and 12% in women (low)
         2. Age 40-49: 51% likelihood (intermediate) in men and 22% in women (low)
         3. Age 50-59: 65% likelihood (intermediate) in men and 31% in women (intermediate)
         4. Age 60-69: 72% likelihood (intermediate) in men and 51% in women (intermediate)
      3. Non-Anginal Chest Pain: 1 criteria from above
         1. Age 30-39: 4% likelihood (low) in men and 2% in women (low)
         2. Age 40-49: 13% likelihood (intermediate) in men and 3% in women (low)
         3. Age 50-59: 20% likelihood (intermediate) in men and 7% in women (low)
         4. Age 60-69: 27% likelihood (intermediate) in men and 14% in women (intermediate)
      4. No criteria present
         1. Risk is low to very low for both men and women
   3. Application
      1. Low risk patient: Avoid stress testing (higher risk of false positives)
      2. Intermediate risk patient: Stress Testing
         1. Exercise Stress Test is first-line for most men and women
         2. Stress Imaging test if abnormal baseline EKG, prior revascularization, or Diabetes Mellitus
         3. Pharmacologic Stress Test if unable to Exercise
      3. High risk patient: Consider coronary angiogram
   4. References
      1. Based on Diamond, Forrester and CASS data
5. Criteria: High Likelihood
   1. Known Coronary Artery Disease history
   2. Typical Anginal symptoms
      1. Men over age 60
      2. Women over age 70
   3. History of variant Angina
   4. EKG in Cardiac Ischemia
      1. Transient Electrocardiogram changes
         1. Associated with pain or hemodynamic changes
      2. ST segment increase or decrease over 1 mm
      3. Deep symmetric T-wave inversion
         1. Occurs in multiple precordial leads
6. Criteria: Intermediate Likelihood (high likelihood features absent)
   1. Typical Anginal symptoms
      1. Men under age 60
      2. Women under age 70
   2. Diabetes Mellitus and Chest Pain
   3. Cardiac Risk Factors (over 1) and Atypical Chest Pain
      1. Pleuritic Chest Pain
      2. Chest Pain primarily in lower or mid Abdomen
      3. Chest Pain localizable with one finger
      4. Reproducible Chest Pain
         1. Exacerbated by movement or palpation of chest wall
      5. Chest Pain is constant and lasts for days
      6. Chest Pain duration only for a few seconds
      7. Chest Pain radiates into legs
   4. Extra-cardiac vascular disease
   5. EKG in Cardiac Ischemia
      1. ST depression of 0.05-1mm
      2. T Wave inversion of over 1 mm
         1. Occurs in leads with dominant R-waves
7. Criteria: Low Likelihood
   1. Can often be discharged from ER with recheck under 72h
   2. Absence of Intermediate likelihood symptoms AND
      1. Age under 60 years old
      2. Atypical Chest Pain
         1. No pressure sensation
         2. No radiation to arm, Shoulder, neck or jaw
      3. Only one Cardiac Risk Factor (not Diabetes Mellitus)
      4. Electrocardiogram normal
         1. T-waves flat or inversion of less than 1 mm
         2. Occurs in dominant R Waves leads
8. Exam: Red Flag signs for Acute Coronary Syndrome
   1. Chest Pain radiating into both arms
   2. New Mitral Regurgitation murmur
   3. Hypotension
   4. Pulmonary Rales
   5. New S3 Gallop rhythm
   6. New Jugular Venous Distention
9. Management
   1. See Acute Coronary Syndrome Immediate Management
10. Evaluation: Testing
    1. Exercise Stress Tests
       1. Test Sensitivity: 55%
       2. Test Specificity: 70%
    2. Thallium Scan
       1. Test Sensitivity: 90%
       2. Test Specificity: 70%
    3. Stress Echocardiogram
       1. Test Sensitivity: 90%
       2. Test Specificity: 86%
    4. PET Scan
       1. Test Sensitivity: 94%
       2. Test Specificity: 92%