CURRENT Essentials of Critical Care.pdf

Chapter 9 Cardiology 115Angina Pectoris■ Essentials of Diagnosis• Heavy, pressure-like substernal chest discomfort; precipitatedby exertion or stress; lasting 15 minutes; relieved with rest ornitroglycerin• Radiation to left arm, neck, or jaw; dyspnea, nausea• Examination usually benign; may detect gallop or mitral regurgitationmurmur during anginal event• ECG varies between normal and ST segment depression; increasedspecificity when dynamic ST segment changes occurwith symptoms• Different stress testing modalities available for diagnostic purpose• Coronary angiography provides anatomical roadmap to guidetherapy■ Differential Diagnosis• Cardiovascular: unstable angina, myocardial infarction,Prinzmetal angina, pericarditis, myocarditis, aortic dissection• Pulmonary: pneumothorax, pulmonary embolism, pneumonia• Gastrointestinal: esophageal reflux or spasm, gastritis, peptic ulcerdisease, cholangitis, hepatitis, pancreatitis• Musculoskeletal pain and costochondritis■ Treatment• Increase oxygen supply and reduce myocardial oxygen demand• Rapid administration of aspirin• Reduce heart rate and blood pressure with beta-blockers• Nitrates for symptom relief• Oxygen• Calcium channel blockers are negative inotropes and coronaryvasodilators; may be used for patients unable to tolerate betablockade• Angioplasty with possible stenting indicated for persistentsymptoms on optimal medical management• Long-term recommendations for behavioral modification, bloodpressure control, addition of HMG-CoA reductase inhibitors■ PearlExcept for left main or three-vessel disease with left ventricular dysfunction,angioplasty and coronary artery bypass graft surgery(CABG) have not yet demonstrated benefits in mortality reduction.ReferenceGibbons RJ et al: ACC/AHA 2002 guideline update for the management ofpatients with chronic stable angina. Circulation 2003;107:149. [PMID:12515758]