Angina pectoris: Chest pain caused by myocardial ischemia
- Simon A Mahler, MD, MS
Simon A Mahler, MD, MS
- Associate Professor of Emergency Medicine
- Wake Forest School of Medicine
- Section Editor
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
Myocardial ischemia is one of the more common causes of chest pain (also termed "chest discomfort") in adults. Angina pectoris, or angina for short, is the term used when chest discomfort is thought to be attributable to myocardial ischemia. In patients with myocardial ischemia, chest discomfort is often but not always present, although other associated symptoms with ischemia may be present (such as exertional shortness of breath, nausea, diaphoresis, fatigue). This has been termed "silent ischemia " or “anginal equivalent,” although it may be more accurately termed "discomfortless or painless ischemia." (See "Silent myocardial ischemia: Epidemiology, pathophysiology, and diagnosis".)
For patients with suspected myocardial ischemia, timely diagnosis and treatment is necessary to treat symptoms and possibly also reduce morbidity and mortality. Rapid diagnosis is particularly important in patients with a possible acute coronary syndrome (unstable angina, non-ST elevation myocardial infarction, or ST-elevation myocardial infarction). (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department".)
This topic will review the pathophysiology, clinical features and diagnosis of ischemic chest discomfort. Discussions of other cardiac and noncardiac causes of chest pain, and their clinical presentations, are found elsewhere. (See "Outpatient evaluation of the adult with chest pain", section on 'Etiologies'.)
PATHOPHYSIOLOGY OF MYOCARDIAL ISCHEMIA
Myocardial ischemia, and consequently angina, occurs whenever myocardial oxygen demand exceeds oxygen supply (table 1). Detailed reviews of the pathophysiology of myocardial ischemia are available in the scientific literature .
Myocardial oxygen demand — There are four major factors that determine myocardial work and therefore myocardial oxygen demand:
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- PATHOPHYSIOLOGY OF MYOCARDIAL ISCHEMIA
- Myocardial oxygen demand
- Myocardial oxygen supply
- MECHANISMS OF ANGINA
- CLINICAL ENTITIES ASSOCIATED WITH MYOCARDIAL ISCHEMIA
- Decreased supply
- Increased demand
- CLINICAL FEATURES
- - Typical qualities of anginal pain
- - Atypical features
- - Associated symptoms
- - Social and family history
- Physical examination
- - Increase in heart rate
- - Elevation in blood pressure
- - New heart sounds
- - New/changed murmurs
- - Precordial pulsation
- Laboratory tests
- Differential diagnosis
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS