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Angina: chest pain (or constricting discomfort) caused by an insufficient…
Angina: chest pain (or constricting discomfort) caused by an insufficient blood supply to the heart muscle
Causes
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Less commonly, angina is caused by valve disease (for example aortic stenosis), hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.
Stable angina usually occurs predictably with physical exertion or emotional stress, and is relieved within minutes of rest, or with a dose of sublingual glyceryl trinitrate.
Unstable angina is new (usually within 24 hours) onset angina, or abrupt deterioration in previously stable angina, often occurring at rest. Unstable angina usually requires immediate admission, or referral to hospital.
Management
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Advice and support should be offered to help achieve and maintain a healthy weight if people are overweight or obese.
An increase in physical activity levels should be encouraged within the limits set by their symptoms.
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Treatment
Sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms of angina and for use before performing activities known to cause symptoms of angina.
A beta-blocker or a calcium-channel blocker as first-line regular treatment to reduce the symptoms of stable angina.
Second-line treatment such as a long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine.
If symptom control is poor on the maximum licensed, or highest tolerated dose of one drug, another drug from a different class should be switched to, or added in.
If symptom control is poor on the maximum licensed, or tolerated doses of two drugs, referral to a cardiologist (for assessment for revascularization) should be arranged.
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Assessment
Physical assessment
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chest examination-palpate for tenderness, assess pain, signs of infection, resp rate, and pulse oximetry
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heart sounds,BP in both arms, JVP, pulse (rate and rhythm), carotid pulse, ankle oedema
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temperature- pyrexia over 38.5oc, infection, pericarditis, pancreatitis
Classify symptoms
typical
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Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
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Risk factors
Stable angina
increasing age, male, presence of CVS risk factors, Hx of CAD
Unstable angina
Pain that is persistent/continuous, unrelated to activity, brought on by breathing, associated with dizziness, palpation's, difficulty in swallowing
Differentials
MSK- rib fracture, spinal disorders, costochondritis
Pulmonary- PE, pneumothorax, CAP, asthma
GI- pancreatitis, oesophageal rupture, GORD, PU disease, cholecystitis
Cardiac- ACS, CCF,Aneurysm
Other-psychogenic, herpes zoster, coxsachie B virus, precordial catch
Referral
Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina.
ECG (electrocardiographic) evidence of previous myocardial infarction or other significant abnormality.
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Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG).
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