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Atypical angina
Cardiac CT angiography shines for
this diagnosis
BY Matthew Bennett, MD and Brett
Heilbron, MD
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Mr. X., a 45-year-old man, goes to his
family physician for an annual physical. During questioning, he discloses
that over the last two months he's been experiencing chest pain. The
pain is sharp in quality and located over the anterior chest. It's
mainly precipitated by exercise and not by emotional stress. It's
usually relieved within 5-10 minutes by rest. He hasn't tried any
medications for this.
Presentation
History
- no hypertension, diabetes mellitus,
hyperlipidemia or family history of premature vascular disease
- smoked for 5 years during college
(about one pack/day)
- no cough, hemoptysis, fever or chills
- no risk factors for deep vein thrombosis
(DVT) or pulmonary embolism (PE), such as family or personal
history of either condition, recent surgery, malignancy,
trauma or immobility
- hasn't started a new exercise regimen,
particularly no push-ups or bench-presses
- doesn't remember having any trauma
to his chest
- has osteoarthritis in his right knee,
for which he takes acetaminophen p.r.n. (his only medication)
Physical examination
- blood pressure (BP): 130/84 mm Hg
- heart rate: 75 beats/min
- rest is normal -- no signs of vascular
disease; normal cardiac examination
Initial tests
- fasting blood sugar: 4.5 mmol/L
- total cholesterol: 4.1 mmol/L
- low-density lipoprotein cholesterol
(LDL-C): 2.8 mmol/L
- high-density lipoprotein cholesterol
(HDL-C): 1.1 mmol/L
- electrocardiogram (ECG): normal sinus
rhythm at 73 beats/min and right bundle-branch block (RBBB)
with repolarization abnormality
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Making the case
When evaluating patients in the office for the workup of chest pain,
it's essential to estimate the probability that they have coronary
artery disease (CAD). This can be done initially through a complete
clinical assessment.
Three descriptors make a patient's chest pain more likely to be
angina:
- substernal chest discomfort with a characteristic quality --
pressure/squeezing/heaviness -- and duration
- provoked by exertion or emotional stress
- relieved by rest or nitroglycerin
Chest pain can be described as typical angina if it has
all three of these characteristics, atypical angina if it
has two, and noncardiac chest pain if there's only one or
none of them.
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