Angina pectoris: Chest pain caused by myocardial ischemia
- Philip J Podrid, MD, FACC
Philip J Podrid, MD, FACC
- Professor of Medicine, Professor of Pharmacology and Experimental Therapeutics
- Boston University School of Medicine
- Lecturer, Harvard Medical School
- Section Editor
- Juan Carlos Kaski, MD, DM, DSc, FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, MD, DM, DSc, FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Head, Cardiovascular Sciences Research Centre
- St. George's, University of London
Myocardial ischemia is one of the more common causes of chest pain in adults. Angina pectoris, or angina for short, is the term used when chest pain is thought to be attributable to myocardial ischemia. In patients with myocardial ischemia, chest pain 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,” although it may be more accurately termed “painless ischemia.” (See "Silent myocardial ischemia: Epidemiology and pathogenesis".)
For those patients suspected of myocardial ischemia, timely diagnosis and treatment is necessary to reduce morbidity and mortality. Rapid diagnosis is particularly important in patients with a possible acute coronary syndrome. (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 pain. Discussions of other cardiac and noncardiac causes of chest pain, and their clinical presentations, are found elsewhere. (See "Diagnostic approach to chest pain in adults" and "Differential diagnosis of chest pain in adults".)
PATHOPHYSIOLOGY OF MYOCARDIAL ISCHEMIA
Myocardial ischemia, and consequently angina, occurs whenever myocardial oxygen demand exceeds oxygen supply (table 1).
Myocardial oxygen demand — There are four major factors that determine myocardial work and therefore myocardial oxygen demand:
- Hillis LD, Braunwald E. Coronary-artery spasm. N Engl J Med 1978; 299:695.
- Ganz P, Abben RP, Barry WH. Dynamic variations in resistance of coronary arterial narrowings in angina pectoris at rest. Am J Cardiol 1987; 59:66.
- Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol 1999; 61:143.
- Benson CJ, Eckert SP, McCleskey EW. Acid-evoked currents in cardiac sensory neurons: A possible mediator of myocardial ischemic sensation. Circ Res 1999; 84:921.
- Longhurst JC, Tjen-A-Looi SC, Fu LW. Cardiac sympathetic afferent activation provoked by myocardial ischemia and reperfusion. Mechanisms and reflexes. Ann N Y Acad Sci 2001; 940:74.
- Fu LW, Longhurst JC. Interactions between histamine and bradykinin in stimulation of ischaemically sensitive cardiac afferents in felines. J Physiol 2005; 565:1007.
- Fu LW, Longhurst JC. Activated platelets contribute to stimulation of cardiac afferents during ischaemia in cats: role of 5-HT(3) receptors. J Physiol 2002; 544:897.
- Fu LW, Guo ZL, Longhurst JC. Undiscovered role of endogenous thromboxane A2 in activation of cardiac sympathetic afferents during ischaemia. J Physiol 2008; 586:3287.
- Sylvén C, Beermann B, Jonzon B, Brandt R. Angina pectoris-like pain provoked by intravenous adenosine in healthy volunteers. Br Med J (Clin Res Ed) 1986; 293:227.
- Lagerqvist B, Sylvén C, Beermann B, et al. Intracoronary adenosine causes angina pectoris like pain--an inquiry into the nature of visceral pain. Cardiovasc Res 1990; 24:609.
- Gaspardone A, Crea F, Tomai F, et al. Muscular and cardiac adenosine-induced pain is mediated by A1 receptors. J Am Coll Cardiol 1995; 25:251.
- Crea F, Gaspardone A, Kaski JC, et al. Relation between stimulation site of cardiac afferent nerves by adenosine and distribution of cardiac pain: results of a study in patients with stable angina. J Am Coll Cardiol 1992; 20:1498.
- Baliga RR, Rosen SD, Camici PG, Kooner JS. Regional myocardial blood flow redistribution as a cause of postprandial angina pectoris. Circulation 1998; 97:1144.
- Chung WY, Sohn DW, Kim YJ, et al. Absence of postprandial surge in coronary blood flow distal to significant stenosis: a possible mechanism of postprandial angina. J Am Coll Cardiol 2002; 40:1976.
- Goldberg AD, Becker LC, Bonsall R, et al. Ischemic, hemodynamic, and neurohormonal responses to mental and exercise stress. Experience from the Psychophysiological Investigations of Myocardial Ischemia Study (PIMI). Circulation 1996; 94:2402.
- Kreiner M, Okeson JP, Michelis V, et al. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc 2007; 138:74.
- Lee TH, Cook EF, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 1985; 145:65.
- Constant J. The clinical diagnosis of nonanginal chest pain: the differentiation of angina from nonanginal chest pain by history. Clin Cardiol 1983; 6:11.
- Christie LG Jr, Conti CR. Systematic approach to evaluation of angina-like chest pain: pathophysiology and clinical testing with emphasis on objective documentation of myocardial ischemia. Am Heart J 1981; 102:897.
- Juneau M, Johnstone M, Dempsey E, Waters DD. Exercise-induced myocardial ischemia in a cold environment. Effect of antianginal medications. Circulation 1989; 79:1015.
- Kearney MT, Charlesworth A, Cowley AJ, MacDonald IA. William Heberden revisited: postprandial angina-interval between food and exercise and meal composition are important determinants of time to onset of ischemia and maximal exercise tolerance. J Am Coll Cardiol 1997; 29:302.
- Schiffer F, Hartley LH, Schulman CL, Abelmann WH. Evidence for emotionally-induced coronary arterial spasm in patients with angina pectoris. Br Heart J 1980; 44:62.
- Henrikson CA, Howell EE, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003; 139:979.
- Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA 1998; 280:1256.
- Braunwald, E, Mark, DB, Jones, RH, et al. Unstable Angina: Diagnosis and Management. Clinical Practice Guideline Number 10 (amended) AHCPR Publication No. 94-0602, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, US Department of Health and Human Services, Rockville, May 1994.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110:588.
- Cook DG, Shaper AG. Breathlessness, angina pectoris and coronary artery disease. Am J Cardiol 1989; 63:921.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.
- Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929.
- 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