General Surgery Rotation

General Surgery: Chest pain; history of angina

Stable angina Chest pain or discomfort, heaviness, pressure, squeezing, tightness that is increased with exertion or emotion

  • Predictable, relieved by rest and/or nitroglycerine
  • Chest pain or substernal pressure
  • Lasts < 10-15 min
  • Relieved with rest or NTG
  • Signs: Levine sign—clenched fist over the sternum and clenched teeth when describing chest pain

Workup:

  • EKG: normal, Q-waves (prior MI)
  • Cardiac stress test demonstrates reversible wall motion abnormalities/ ST depression >1 mm
  • Coronary angiography provides a definitive diagnosis
    • If severely symptomatic despite medical therapy and being considered for PCI
    • Patients with troublesome symptoms difficult to diagnose
    • Angina symptoms in a patient who has survived a cardiac death event and patients with ischemia on noninvasive testings

Treatment:

    • Nitroglycerin sublingual → IV NTG
    • Beta-blockers
    • Severe: angioplasty and bypass

Prognosis:

  • Depends on LVEF: < 50% (increased mortality)
  • Vessel(s) Involved: left main (poor, 2/3 of the heart)
Unstable angina Chest pain or discomfort, heaviness, pressure, squeezing, tightness that is increased with exertion or emotion

  • Previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
    • Chronic angina—increasing in frequency, duration, or intensity of pain
    • New-onset angina—severe and worsening
    • Angina at rest
  • O2 demand unchanged, supply decreased, secondary to low resting coronary flow

Workup:

  • EKG: ST-segment or T-wave abnormalities
  • Cardiac enzymes: normal troponin, CK-MB

Treatment

  • Admit to the unit with continuous cardiac monitoring, establish IV access, O2
  • Pain control with NTG and morphine
  • ASA and/or clopidogrel - (Plavix reduces the incidence of MI in patients with unstable angina compared with ASA alone 9-12 months of therapy)
  • LMWH continued for at least 2 days
  • β-Blockers
  • LMWH
  • Replace electrolytes
  • If the patient responds to medical therapy → stress test to determine if catheterization/revascularization necessary
  • Revascularization if symptoms persist despite medical therapy
  • Reduce risk factors: stop smoking, weight loss, treat DM/HTN
  • ACE inhibitors and statins - start patients with unstable angina or NSTEMI with high LDL on HMG-CoA reductase inhibitor (statin)
Prinzmetal variant angina Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot

  • Smooth muscle constriction (spasm) of the coronary artery without obstruction → leads to MI, ventricular arrhythmias, sudden death
  • Known triggers: hyperventilation, cocaine or tobacco use, provocative agents (acetylcholine, ergonovine, histamine, serotonin)
  • Nitric oxide deficiency → increased activity of potent vasoconstrictors and stimulators of smooth muscle proliferation 50-y-old, females

Nonexertional chest pain similar to unstable angina

  • Preservation of exercise capacity
  • Look for a history of smoking (#1 risk factor) or cocaine abuse
  • Pain is cyclical (mostly occur in morning hours, no correlation to cardiac workload)

Diagnostics:

  • EKG may show inverted U waves, ST-segment or T-wave abnormalities
  • Cardiac enzymes: normal troponin, CK-MB
  • Check Mg level, CBC, CMP, lipid panel

Treatment:

  • Stress testing with myocardial perfusion imaging or coronary angiography
  • Pharmacotherapy SL, topical, or IV nitrates (initial)
  • Antiplatelet, thrombolytics, statins, BB
  • Once diagnosis made—CCB and long-acting nitrates used for long-term prophylaxis (amlodipine)

Congratulations - you have completed Unsable Angina. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
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Question 1
A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is on and around my chest". This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains inactive the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis?
A
Acute myocardial infarction
Hint:
Pain does not resolve in an acute MI, it gradually gets worse.
B
Prinzmetal variant angina
Hint:
Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest.
C
Stable angina
Hint:
Pain in stable angina is relieved with rest and usually resolves within 10 minutes. angina does not have pain at rest.
D
Unstable angina
Question 1 Explanation: 
Pain in unstable angina is precipitated by less effort than before or occurs at rest.
Question 2
A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is
A
daily aspirin to prevent MI.
Hint:
See D for explanation.
B
nitrate therapy for the angina.
Hint:
See D for explanation.
C
aggressive risk factor reduction.
Hint:
See D for explanation.
D
referral for coronary artery revascularization.
Question 2 Explanation: 
Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.
Question 3
A 60 year-old male with history of hypertension and hyperlipidemia presents with intermittent chest heaviness for one month. The patient states he has had occasional heaviness in his chest while walking on his treadmill at home or shoveling snow. He also admits to mild dyspnea on exertion. His symptoms are relieved with 2-3 minutes of rest. He denies lightheadedness, syncope, orthopnea or lower extremity edema. Vitals reveal a BP of 130/90, HR 70, regular, RR 14. Cardiac examination revealed a normal S1 and S2, without murmur or rub. Lungs were clear to auscultation. Extremities are without edema. EKG reveals no acute change and cardiac enzymes are negative. Which of the following is the most appropriate next diagnostic study?
A
cardiac catheterization
Hint:
Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings, a stress test is a better initial diagnostic study for this patient.
B
nuclear exercise stress test
C
helical (spiral) CT
Hint:
Helical CT is used in the diagnosis of pulmonary embolism, not in the evaluation of angina.
D
transthoracic Echocardiogram
Hint:
Echocardiogram is used in the evaluation of valvular heart disease not in the evaluation of suspected myocardial ischemia.
Question 3 Explanation: 
This patient has signs and symptoms of classic angina; nuclear stress testing is the most useful noninvasive procedure for diagnosis of ischemic heart disease and evaluation of angina in this patient.
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