Content:
Clinical Presentation
Content on this page:
Clinical Presentation
History
Physical Examination
Screening
Content on this page:
Clinical Presentation
History
Physical Examination
Screening
Clinical Presentation
A good history and clinical examination are the key first step in the evaluation of a patient with chest pain and/or dyspnea. Evaluation of cardiovascular (CV) risk factors, medical history and symptom characteristics (eg onset, type, duration, location, triggers, relieving factors, time of day) is recommended.
Chronic Coronary Syndromes_Initial Assesment 1
Chronic Coronary Syndromes_Initial Assesment 1History
A thorough history is the initial diagnostic management for all clinical scenarios within the chronic coronary syndromes’ spectrum. Chronic coronary syndromes should be considered when presenting with the following symptoms as potential angina equivalents: Chest pain precipitated by emotional stress, dyspnea or dizziness on exertion, pain in the arms, jaw, neck or upper back, or fatigue. In many cases, it is possible to make a diagnosis based on the history of chest pain alone but physical exam and diagnostic tests are necessary to confirm the diagnosis (eg silent myocardial ischemia), determine the cause and assess the severity of the underlying disease.
Signs and Symptoms
Chest discomfort
Quality
Patients having chest discomfort described as strangling, constricting, squeezing, pressure or heaviness have an increased likelihood of chronic coronary syndromes. Patients having chest discomfort described as burning, sharp, tearing or ripping, pleuritic or aching have decreased likelihood of chronic coronary syndromes.
Location and Size
Patients with retrosternal discomfort, extending to left arm or to jugular or intrascapular region or fist-sized chest discomfort have an increased likelihood of chronic coronary syndromes. Patients with right, shifting, large area or fine spot of chest discomfort have decreased likelihood of chronic coronary syndromes.
Duration
Patients with short (up to 5-10 minutes) chest discomfort if precipitated by physical exertion or emotion have increased likelihood of chronic coronary syndromes. Patients with lasting chest discomfort have decreased likelihood of chronic coronary syndromes.
Precipitating Factors/Trigger
Chest discomfort triggered by effort, more frequent in cold weather, strong winds or after a heavy meal or emotional distress (eg anger, anxiety, excitation or nightmare) is most likely chronic coronary syndromes. Chest discomfort triggered at rest, on deep inspiration or when coughing or when pressing on ribs or sternum is less likely chronic coronary syndrome.
Alleviating Factors
Chest discomfort subsiding within 1-5 minutes after effort discontinuation or relief is accelerated by sublingual Nitroglycerin is most likely chronic coronary syndromes. Chest discomfort relieved by antacids or drinking milk is less likely to be chronic coronary syndromes.
Dyspnea
Quality
Patients with difficulty catching breath are most likely to have chronic coronary syndromes. Patients with difficulty exhaling or with wheezing are less likely to have chronic coronary syndromes.
Precipitating Factors/Trigger
Dyspnea triggered by effort is more likely chronic coronary syndromes. Dyspnea triggered both at rest and on effort or while coughing is less likely caused by chronic coronary syndromes.
Alleviating Factors
Dyspnea rapidly subsiding after effort discontinuation is more likely chronic coronary syndromes. Dyspnea slowly subsiding at rest or after inhalation of bronchodilators is less likely caused by chronic coronary syndromes.
Conditions that Exacerbate or Provoke Ischemia
Non-cardiac Diseases
Non-cardiac diseases that exacerbate or provoke ischemia are hyperthyroidism, hyperthermia, anxiety, anemia, hyperviscosity, leukemia, hypertension, sympathomimetic toxicity (eg cocaine toxicity), arteriovenous fistulae, sickle cell disease, polycythemia, thrombocytosis, pheochromocytoma, carbon monoxide poisoning, hypergammaglobulinemia, and hypoxemia secondary to pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, interstitial pulmonary fibrosis.
Cardiac Diseases
Cardiac diseases that exacerbate or provoke ischemia are arrhythmias (eg supraventricular tachycardia, ventricular tachycardia), aortic stenosis, dilated cardiomyopathy, hypertrophic cardiomyopathy, significant coronary obstruction and microvascular disease.
Signs and Symptoms
Chest discomfort
Quality
Patients having chest discomfort described as strangling, constricting, squeezing, pressure or heaviness have an increased likelihood of chronic coronary syndromes. Patients having chest discomfort described as burning, sharp, tearing or ripping, pleuritic or aching have decreased likelihood of chronic coronary syndromes.
Location and Size
Patients with retrosternal discomfort, extending to left arm or to jugular or intrascapular region or fist-sized chest discomfort have an increased likelihood of chronic coronary syndromes. Patients with right, shifting, large area or fine spot of chest discomfort have decreased likelihood of chronic coronary syndromes.
Duration
Patients with short (up to 5-10 minutes) chest discomfort if precipitated by physical exertion or emotion have increased likelihood of chronic coronary syndromes. Patients with lasting chest discomfort have decreased likelihood of chronic coronary syndromes.
Precipitating Factors/Trigger
Chest discomfort triggered by effort, more frequent in cold weather, strong winds or after a heavy meal or emotional distress (eg anger, anxiety, excitation or nightmare) is most likely chronic coronary syndromes. Chest discomfort triggered at rest, on deep inspiration or when coughing or when pressing on ribs or sternum is less likely chronic coronary syndrome.
Alleviating Factors
Chest discomfort subsiding within 1-5 minutes after effort discontinuation or relief is accelerated by sublingual Nitroglycerin is most likely chronic coronary syndromes. Chest discomfort relieved by antacids or drinking milk is less likely to be chronic coronary syndromes.
Dyspnea
Quality
Patients with difficulty catching breath are most likely to have chronic coronary syndromes. Patients with difficulty exhaling or with wheezing are less likely to have chronic coronary syndromes.
Precipitating Factors/Trigger
Dyspnea triggered by effort is more likely chronic coronary syndromes. Dyspnea triggered both at rest and on effort or while coughing is less likely caused by chronic coronary syndromes.
Alleviating Factors
Dyspnea rapidly subsiding after effort discontinuation is more likely chronic coronary syndromes. Dyspnea slowly subsiding at rest or after inhalation of bronchodilators is less likely caused by chronic coronary syndromes.
Conditions that Exacerbate or Provoke Ischemia
Non-cardiac Diseases
Non-cardiac diseases that exacerbate or provoke ischemia are hyperthyroidism, hyperthermia, anxiety, anemia, hyperviscosity, leukemia, hypertension, sympathomimetic toxicity (eg cocaine toxicity), arteriovenous fistulae, sickle cell disease, polycythemia, thrombocytosis, pheochromocytoma, carbon monoxide poisoning, hypergammaglobulinemia, and hypoxemia secondary to pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, interstitial pulmonary fibrosis.
Cardiac Diseases
Cardiac diseases that exacerbate or provoke ischemia are arrhythmias (eg supraventricular tachycardia, ventricular tachycardia), aortic stenosis, dilated cardiomyopathy, hypertrophic cardiomyopathy, significant coronary obstruction and microvascular disease.
Physical Examination
Chronic Coronary Syndromes_Initial Assesment 2The physical examination is usually normal or nonspecific in stable angina patients. Examination during or immediately after an episode of pain may be beneficial since S4 or S3 heart sound or gallop, mitral regurgitation murmur, paradoxically split S2, basilar rales or chest wall heave that dissipates when pain decreases are all predictive of ischemic heart disease. A careful cardiovascular exam may reveal other related conditions such as heart failure (HF), valvular heart disease or hypertrophic cardiomyopathy. An audible rub suggests pericardial or pleural disease. The presence of carotid bruit, renal artery bruit, diminished pedal pulse or palpable abdominal aneurysm is evidence of vascular disease. Elevated blood pressure (BP), corneal arcus, xanthomas and retinal exudates are signs that suggest the presence of ischemic heart disease risk factors. Chest pain elicited by pressure on the chest wall can be caused by musculoskeletal syndromes but does not eliminate the possibility of angina due to ischemic heart disease. Body mass index (BMI), waist circumference and waist-to-hip ratio should also be taken to determine possible metabolic syndrome, non-coronary vascular disease and other signs of comorbid conditions. Thyroid enlargement or signs of anemia may also be present.
Screening
Risk Stratification
Risk refers to the risk of cardiovascular events (eg death). An annual mortality rate of low risk is <1%, in intermediate risk is 1-3% and in high risk is >3%. An initial risk of adverse events stratification based on basic clinical assessment (eg electrocardiography [ECG], anginal threshold, diabetes, chronic kidney disease, left ventricular ejection fraction [LVEF]) is recommended. Integration of demographic, social and medical variables with clinical findings, non-invasive (eg resting electrocardiogram, response to stress testing, quantification of left ventricular function and extent of coronary artery disease) and/or invasive diagnostic tests or validated risk scores is recommended to determine the level of risk. This is recommended in patients with established chronic coronary syndromes and new or worsening symptoms preferably with the use of stress imaging. This assists in deciding the appropriate therapy and determines the prognosis of the disease. Low-risk patients are managed with risk factor reduction with or without antianginal therapy, while intermediate to high-risk patients are referred to specialists for further evaluation and possible revascularization.
Thrombotic risk is high in a chronic coronary syndrome patient in the presence of any one of the following: Coronary [previous coronary event, high-risk coronary anatomy (eg bifurcation percutaneous coronary intervention [PCI], left main percutaneous coronary intervention, multivessel percutaneous coronary intervention, >3 stents), or documented multivessel coronary disease]; vascular [established peripheral artery disease (eg carotid stenosis >50%, renal artery stenosis, mesenteric artery disease, claudication or previous peripheral intervention) or cerebrovascular disease (eg transient ischemic attacks [TIA] or ischemic stroke from atherosclerosis)]; and disease (heart failure from coronary artery disease, diabetes on therapy, estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, micro- and macroalbuminuria).
The potential features which are associated with higher risk of major adverse cardiovascular events (MACE) in chronic coronary syndromes patients include the following: Demographic and socioeconomic status (age, male sex, poor social support, poverty or lack of health care access); past or current medical and mental health conditions (elevated body mass index, previous MI, percutaneous coronary intervention or coronary artery bypass graft [CABG], heart failure, atrial fibrillation or flutter, diabetes, dyslipidemia, CKD, current or previous smoker, peripheral artery disease, depression, poor adherence with goal-directed therapy); biomarkers (high-sensitivity troponin, B-type natriuretic peptide); and ancillary cardiac testing or imaging (inability to exercise; angina with stress); ECG (Left bundle branch block [LBBB] or left ventricular hypertrophy or higher resting heart rate [HR]); echocardiography (reduced left ventricular ejection fraction or left ventricular hypertrophy); exercise stress test (higher Duke treadmill score [DTS] of < -10, higher resting heart rate, achieved heart rate <85% predicted); exercise or Dobutamine stress echocardiography (higher DTS, lower exercise workload, peak rate-pressure product <15,000, coronary flow reserve [CFR] <2, no change or increase in left ventricular end-systolic volume, reduced EF, ischemic ECG changes with stress, ≥3 of 16 segments with stress-induced hypokinesia or akinesia); single-photon emission computed tomography (SPECT) or positron emission tomography (PET) (percentage fixed myocardium on SPECT, transient ischemic dilation with stress, reduced coronary flow reserve, ischemic); ECG changes with stress, ≥10% area of ischemia of the left ventricular myocardium; higher calcium score alone and in addition to functional imaging; CCTA showing total plaque burden, high-risk plaque (positive remodeling [remodeling index >1.1], low attenuation [mean CT number <30 Hounsfield units], or napkin-ring sign), reduced CT-fractional flow reserve (FFR); left main disease with ≥50% stenosis, 3-vessel disease with ≥70% stenosis or 2-vessel disease with ≥70% stenosis including the proximal left anterior descending (LAD) or 1-vessel disease of the proximal left anterior descending with ≥70% stenosis and CT-FFR ≤0.8; cardiac magnetic resonance (CMR) (reduced left ventricular and/or right ventricular EF, left ventricular hypertrophy, scar or infarct, reduced myocardial perfusion reserve, myocardial blood flow at stress); and stress CMR (≥2 of 16 segments with stress perfusion defects or ≥3 Dobutamine-induced dysfunctional segments).
Chronic coronary syndrome patients without a clinical or functional status change are not recommended to undergo routine periodic anatomic or ischemic testing for risk stratification or therapeutic decision-making.
Pre-test Likelihood Estimation of Obstructive Atherosclerotic Coronary Artery Disease
Estimation of pre-test likelihood of obstructive epicardial coronary artery disease using the Risk Factor-weighted Clinical Likelihood (RF-CL) model is recommended. The RF-CL model includes age, angina symptoms, sex and number of risk factors (eg diabetes, dyslipidemia, family history, hypertension, smoking). The main symptom score of 0-3 points for chest pain (1 point for type and location of chest pain [constricting discomfort located retrosternally or in neck, jaw, shoulder or arm], 1 point for precipitating factor [physical or emotional stress], 1 point for relieving factors [rest or nitrates within 5 minutes]) and 2 points for dyspnea (shortness of breath and/or trouble catching breath aggravated by physical exertion) is noted. Diabetes, dyslipidemia and hypertension were present at the time of diagnosis. Family history of coronary artery disease is defined as ≥1 first-degree relatives with early signs of coronary artery disease (<55 years of age in men and <65 years of age in women). Smoking as a current or past smoker is also noted.
The Risk Factor-weighted Clinical Likelihood (RF-CL) classifies pre-test likelihood of obstructive coronary artery disease into:
Coronary artery calcium score (CACS) should be considered in patients with a low pre-test likelihood of obstructive coronary artery disease to reclassify patients and identify more patients with a very low CACS-weighted clinical likelihood. Further diagnostic tests may be deferred in patients reclassified based on CACS from a low to very low likelihood of coronary artery disease. Further diagnostic testing based on the adjusted clinical likelihood and coronary calcium burden should be performed if CACS is high with the presence of clinical findings suggesting that the RF-CL model may be underestimating the likelihood of obstructive coronary artery disease.
Chronic Coronary Syndromes_Initial Assesment 3
Exercise electrocardiogram and detection of atherosclerotic disease in non-coronary arteries may be considered in patients with an initially low likelihood of obstructive coronary artery disease to adjust the pre-test likelihood estimate. Patients with moderate or high pre-test likelihood of obstructive coronary artery disease should be referred for a non-invasive anatomical or functional imaging to establish chronic coronary syndromes diagnosis and evaluation of risk for future cardiac events. Patients with very high pre-test likelihood of obstructive coronary artery disease should undergo invasive coronary angiography (ICA) to confirm chronic coronary syndromes.
Risk refers to the risk of cardiovascular events (eg death). An annual mortality rate of low risk is <1%, in intermediate risk is 1-3% and in high risk is >3%. An initial risk of adverse events stratification based on basic clinical assessment (eg electrocardiography [ECG], anginal threshold, diabetes, chronic kidney disease, left ventricular ejection fraction [LVEF]) is recommended. Integration of demographic, social and medical variables with clinical findings, non-invasive (eg resting electrocardiogram, response to stress testing, quantification of left ventricular function and extent of coronary artery disease) and/or invasive diagnostic tests or validated risk scores is recommended to determine the level of risk. This is recommended in patients with established chronic coronary syndromes and new or worsening symptoms preferably with the use of stress imaging. This assists in deciding the appropriate therapy and determines the prognosis of the disease. Low-risk patients are managed with risk factor reduction with or without antianginal therapy, while intermediate to high-risk patients are referred to specialists for further evaluation and possible revascularization.
Thrombotic risk is high in a chronic coronary syndrome patient in the presence of any one of the following: Coronary [previous coronary event, high-risk coronary anatomy (eg bifurcation percutaneous coronary intervention [PCI], left main percutaneous coronary intervention, multivessel percutaneous coronary intervention, >3 stents), or documented multivessel coronary disease]; vascular [established peripheral artery disease (eg carotid stenosis >50%, renal artery stenosis, mesenteric artery disease, claudication or previous peripheral intervention) or cerebrovascular disease (eg transient ischemic attacks [TIA] or ischemic stroke from atherosclerosis)]; and disease (heart failure from coronary artery disease, diabetes on therapy, estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, micro- and macroalbuminuria).
The potential features which are associated with higher risk of major adverse cardiovascular events (MACE) in chronic coronary syndromes patients include the following: Demographic and socioeconomic status (age, male sex, poor social support, poverty or lack of health care access); past or current medical and mental health conditions (elevated body mass index, previous MI, percutaneous coronary intervention or coronary artery bypass graft [CABG], heart failure, atrial fibrillation or flutter, diabetes, dyslipidemia, CKD, current or previous smoker, peripheral artery disease, depression, poor adherence with goal-directed therapy); biomarkers (high-sensitivity troponin, B-type natriuretic peptide); and ancillary cardiac testing or imaging (inability to exercise; angina with stress); ECG (Left bundle branch block [LBBB] or left ventricular hypertrophy or higher resting heart rate [HR]); echocardiography (reduced left ventricular ejection fraction or left ventricular hypertrophy); exercise stress test (higher Duke treadmill score [DTS] of < -10, higher resting heart rate, achieved heart rate <85% predicted); exercise or Dobutamine stress echocardiography (higher DTS, lower exercise workload, peak rate-pressure product <15,000, coronary flow reserve [CFR] <2, no change or increase in left ventricular end-systolic volume, reduced EF, ischemic ECG changes with stress, ≥3 of 16 segments with stress-induced hypokinesia or akinesia); single-photon emission computed tomography (SPECT) or positron emission tomography (PET) (percentage fixed myocardium on SPECT, transient ischemic dilation with stress, reduced coronary flow reserve, ischemic); ECG changes with stress, ≥10% area of ischemia of the left ventricular myocardium; higher calcium score alone and in addition to functional imaging; CCTA showing total plaque burden, high-risk plaque (positive remodeling [remodeling index >1.1], low attenuation [mean CT number <30 Hounsfield units], or napkin-ring sign), reduced CT-fractional flow reserve (FFR); left main disease with ≥50% stenosis, 3-vessel disease with ≥70% stenosis or 2-vessel disease with ≥70% stenosis including the proximal left anterior descending (LAD) or 1-vessel disease of the proximal left anterior descending with ≥70% stenosis and CT-FFR ≤0.8; cardiac magnetic resonance (CMR) (reduced left ventricular and/or right ventricular EF, left ventricular hypertrophy, scar or infarct, reduced myocardial perfusion reserve, myocardial blood flow at stress); and stress CMR (≥2 of 16 segments with stress perfusion defects or ≥3 Dobutamine-induced dysfunctional segments).
Chronic coronary syndrome patients without a clinical or functional status change are not recommended to undergo routine periodic anatomic or ischemic testing for risk stratification or therapeutic decision-making.
Pre-test Likelihood Estimation of Obstructive Atherosclerotic Coronary Artery Disease
Estimation of pre-test likelihood of obstructive epicardial coronary artery disease using the Risk Factor-weighted Clinical Likelihood (RF-CL) model is recommended. The RF-CL model includes age, angina symptoms, sex and number of risk factors (eg diabetes, dyslipidemia, family history, hypertension, smoking). The main symptom score of 0-3 points for chest pain (1 point for type and location of chest pain [constricting discomfort located retrosternally or in neck, jaw, shoulder or arm], 1 point for precipitating factor [physical or emotional stress], 1 point for relieving factors [rest or nitrates within 5 minutes]) and 2 points for dyspnea (shortness of breath and/or trouble catching breath aggravated by physical exertion) is noted. Diabetes, dyslipidemia and hypertension were present at the time of diagnosis. Family history of coronary artery disease is defined as ≥1 first-degree relatives with early signs of coronary artery disease (<55 years of age in men and <65 years of age in women). Smoking as a current or past smoker is also noted.
The Risk Factor-weighted Clinical Likelihood (RF-CL) classifies pre-test likelihood of obstructive coronary artery disease into:
- Very low: ≤5%
- Low: >5-15%
- Moderate: >15-50%
- High: >50-85%
- Very high: >85%
Coronary artery calcium score (CACS) should be considered in patients with a low pre-test likelihood of obstructive coronary artery disease to reclassify patients and identify more patients with a very low CACS-weighted clinical likelihood. Further diagnostic tests may be deferred in patients reclassified based on CACS from a low to very low likelihood of coronary artery disease. Further diagnostic testing based on the adjusted clinical likelihood and coronary calcium burden should be performed if CACS is high with the presence of clinical findings suggesting that the RF-CL model may be underestimating the likelihood of obstructive coronary artery disease.
Chronic Coronary Syndromes_Initial Assesment 3Exercise electrocardiogram and detection of atherosclerotic disease in non-coronary arteries may be considered in patients with an initially low likelihood of obstructive coronary artery disease to adjust the pre-test likelihood estimate. Patients with moderate or high pre-test likelihood of obstructive coronary artery disease should be referred for a non-invasive anatomical or functional imaging to establish chronic coronary syndromes diagnosis and evaluation of risk for future cardiac events. Patients with very high pre-test likelihood of obstructive coronary artery disease should undergo invasive coronary angiography (ICA) to confirm chronic coronary syndromes.