How to differentiate between anginal chest pain and other chest pain

1Differences between angina chest pain  and myocardial infarction chest pain
2Differences between angina, chest pain  and oesophageal pain
3Investigation should done for newly diagonsed hypertensive patient
4Type of therapy/treatment
5Clinical evaluation of a hypertensive patient for target organ damage

Angina pectoris:

Angina pectoris is a group of symptoms brought on by transient myocardial ischaemia, which happens when there is a difference between how much oxygen the heart gets and how much it needs.

Now, for better understanding and differentiation of angina from other chest diseases, we must know the types of angina .

Types:

1.Stable / classical/  or typical angina: These types of attacks typically result from atherosclerosis and appear during physical activity rather than rest.

2. Unstable angina, also known as crescendo angina, this type of chest pain that occurs with less physical exercise or during periods of rest. This type of angina is caused by the atherosclerotic plaque, or mural thrombus , when it blocks the coronary artery.

3. Angina Prinzmetal or Variant Angina: This type of angina can develop during rest; however, there is no involvement of atherosclerosis to cause this type of angina. The main reason behind this is vasospasm in the coronary arteries.

The following are some particular types of angina:

1. Crescendo angina: It is a special form of unstable angina in which patients suffer from angina pain almost every day.

2. Angina pectoris nocturna, also known as decubitus angina, is a type of chest pain that usually starts while the patient is sleeping. It is mainly caused by either an increase in venous return due to lying down or a decrease in the effectiveness of anti-anginal medications that are typically used in the morning by the patient. In most cases, this indicates serious coronary disease.

After knowing types, we must look at this point during history taking. This point is very useful for Daigonsis:

Points in history taking in a patient with chest discomfort to diagnose anginal pain :

Site of pain: The onset of the anginal pain is central, and retrosternal.

Radiation of pain: Anginal pain radiates to the neck, jaw, and arms.

Aggravating factors: Angina is aggravated by exertion, excitement, emotion, cold exposure, and heavy

meal.

Relieving factors: Angina is relieved by rest and nitroglycerine.

History: Previous angina or myocardial infarction.

presence of Hypertension.

– Presence of diabetes mellitus.

Habits of Smoking, alcohol, and caffeine consumption.

Occupational history, such as exposure to colds, may aggravate angina.

Family history of ischaemic heart disease, hypertension, diabetes mellitus, and cardiomyopathy plays a great demarking point to identify angina pain.

History of Angioplasty or Coronary Bypass

history of hypercholesterolemia.

 Points in history taken in a patient with chest discomfort to diagnose pericarditis pain :

Site: Retrosternal.

Radiation: It might be felt all the way to the back and left shoulder.

It’s likely that a viral sickness will act as a prodrome before it.

Initiation: There is not a clear initially causing factor; the intensity has a tendency to fluctuate.

Nature: May be stabbing or raw, like sand paper. Often described as sharp, rarely as tight or heavy.

Aggravating factors : Changes in posture, respiration.

Relieving factor: analgesics, especially NSAIDs.

Associated characteristic is pericardial rub.

Points in the patient’s history that led to the diagnosis of aortic dissection pain in a patient who presented with chest discomfort

Location: The pain typically occurs primarily in the space between the shoulder blades or behind the sternum.

 Onset: Often abrupt.

Severity: Very severe.

Nature: Sharp, pricking, stabbing, or knife-like in nature; also frequently described as ‘tearing’ in nature.

No relieving factors: It has a  the tendency to continue exists. Patients are frequently restless because of the pain they are experiencing.

Associated features: Associated symptoms and signs include syncope, focused neurological symptoms and signs, hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur, and syncope. 

Now we see a comparison between angina pain and other kinds of chest pain.

Differences between angina chest pain  and myocardial infarction chest pain :

  1. Relieving factors for anginal chest pain By rest, nitrates And on the other hand, myocardial infarction chest pain is not relieved by rest, or nitrates.
  2. in terms of severity, chest pain due to angina is mild to moderate. but in my myocardial infraction, the chest pain is severe.
  3. The anxiety level of a patient may be present or absent, but in myocardial infarction, the anxiety level is severe.
  1. Sympathetic activity does not increase in anginal chest pain; on the other hand, sympathetic activity increases in myocardial 
  1. There are some symptoms that may not be present in anginal chest pain, such as sweating, nausea and vomiting, cold and calm skin, and hypotension  but in myocardial infraction, nausea and vomiting, sweating, cold calmy skin, and hypotension are commonly seen.

Differences between angina, chest pain  and oesophageal pain:

  1. First of all, we have to look at the site where the pain is. The site of the pain plays an important role in diagnosing the reason behind the pain. In angina chest pain, the site of the pain is retrosternal, and in case of oesophageal pain, it is usually in the retrosternal or epigestric region of the abdomen.
  2. Usually, angina pain is relieved by taking rest, but in oesophageal pain, taking rest don’t reduce pain.
  3. Angina pain is relieved by taking nitrates, but oesophageal pain is not relieved by taking nitrates.
  4. Angina pain radiates to the arm and jaw, but oesophageal pain usually does not radiate.

What investigation should done for newly diagonsed hypertensive patient

Supposed a patient come to you and you find that patent is suffering from severe hypertension and you are the first one who diagonosis this. Now lets disccuse what should be your future diagnosis, investigation and treatment plan –

 Clinical assessment of case of hypertension:

History taking

  1. The history of a person’s family is an important factor. Because a child whose parents have high blood pressure has a much greater chance developing high blood pressure themselves
  2. Lifestvle (exercise, salt intake, smoking habit).
  3. Drug or alcohol intake.
  4.  4. Secondary hypertension such as phaeochromocytoma (paroxysmal headache, palpitations, and sweating), hypo or hyperthyroidism, or complications which include coronary artery disease (e.g. angina, shortness of breath), history of medication (e.g. OCP in females, steroid).

Examination to be performed :

1. such as radio-femoral delay (aortic coarctation).

2. Enlargement of the kidneys (to diagonsis polycystic kidney disease).

3.Renal bruits (stenosis of the renal artery).

4.Cushing’s syndrome is marked by facial and bodily traits.

5. Characteristics of significant risk factors, including central adiposity and hyperlipidemia (tendon xanthomas, etc.).

Non-specific findings:

1. Hypertrophy of the left ventricle (apical effusion).

2.The aortic component of the second heart sound is particularly highlighted along with the 4th heart sound.

3. Ophthalmoscopy / funduscopy: For the diagnosis of hypertensive retinopathy.

4. The evidence of generalized atherosclerosis or especially complications, such as aortic aneurysm or peripheral vascular disease.

Investigations:

Minimum (baseline / initial) investigations for newly diagnosed hypertension (in all patients) include

1. blood, protein, and glucose urine test.

2. Urine, electrolytes, and serum creatinine levels.

3. Blood glucose.

4.Total and high-density lipoprotein (HDL) cholesterol levels in the blood.

  • ECG with 12 leads (hypertrophy of the left ventricle and coronary artery disease).
  • Other research (in specific patients): 1. Chest X-ray: to diagnose cardiomegaly, cardiac failure, and coarctation of the aorta.
  • The purpose of ambulatory blood pressure monitoring is to diagnose borderline or ‘white coat’ hypertension.
  • 3. Echocardiogram: to detect or quantify hypertrophy of the left ventricle.
  • 4. Ultrasound of the kidneys: to detect suspected renal disease.
  • 5. The purpose of renal angiography is to detect or corroborate the presence of renal artery stenosis.
  • 6. Urinary catecholamines: to detect the possibility of phaeochromocytoma.
  • 7. Urinary cortisol and dexamethasone suppression test: to identify the possibility of Cushing’s syndrome.
  • 8. Plasma renin activity and aldosterone: to searching for the potential primary aldosteronism.
  • 9. Examinations for thyrotoxicosis and hypothyroidism of the thyroid.

If patient complain that he is suffering from severe hypertension for a prolonged time then most probably he has developed some target organ damage. Now here is some investigation to find out this-

Suggest necessary investigations with expected findings.

a) Clinical evaluation of a hypertensive patient for target organ damage:

1. Features of LVH: Heaving apex beat.

2.For retinopathy: Ophthalmoscopy.

3.For nephropathy: Bed side urine examination for proteinuria.

4.Evidence of generalized atheroma or specific complications such as aortic aneurysm or peripheral vascular disease.

b) Necessary investigations with expected findings:

1.Urine R/E: For blood, protein and glucose.

2.Blood urea, electrolvtes and serum creatinine: To se status of renal function.

3.Blood glucose: For DM.

4.Fasting lipid profile: For dyslipidaemia.

5. ECG: For evidence of left ventricular hypertrophy, coronary artery disease.

If hypertension does not treat on time then they may delvoped serious complication. Complications of hypertension / target organ damage by hypertension are usually:

the adverse effects of hypertension principally involve the blood vessels, central nervous system, retina, heart and kidneys, and can often be detected clinically.

1) Blood vessels: Atherosclerosis, Aneurysm.

2) Central nervous system:

Stroke (due to cerebral hemorrhage or cerebral infarction), Carotid atheroma and transient cerebral ischaemic attacks, Subarachnoid haemorrhage, Hypertensive encephalopathy, Papilloedema.

3)Retina: Hypertensive retinopathy, Central retinal vein thrombosis.

4)Heart: Coronary artery disease, Left ventricular hypertrophy and failure, Atrial fibrillation.

5) Kidneys: Proteinuria, CKD.

So after finally after your diagoniss you have to  start treatement of hypertension:

There are 2 type of therapy/treatment-

A-Non-drug therapv:

a.Correction of obesity.

b.Stoppage of smoking.

c.Reducing alcohol intake.

d.Restricting salt intake.

e.Taking regular physical exercise.

f.Increasing consumption of fruit and vegetables.

Antihypertensive drugs therapy/treatment:

A: ACE inhibitors (Ramipril 5-10 mg daily, Enalapril 5-40 mg daily etc.) and angiotensin-receptor blocker (Losartan 50-100 mg daily, Irbesartan 75:300 mg daily, Valsartan 40-160 mg daily etc.).

B: Beta blockers (Atenolol 50-100 mg daily. Metoprolol 100-200 mg daily, Bisoprolot 5-10 mg daily etc.)

C: Calcium channel blockers (eg. Amlodipine 5-10 mg daily, Nifedipine 30-90 mg daily).

D: Diuretics. Thiazide diuretics (Hydrochlorthiazide 12.5-25 mg daily) and potent loop diuretics (Frusemide 40 mg daily, bumetanide I mg daily).

Others:

E: Both alpha and Beta blockers: Carvedilol, labetalol.

F: Alpha blockers: Prazosin 0.5-20 mg daily in divided doses, doxazosin 1-16 mg daily.

G: Centrally acting drugs: Methyldopa 250 mg 8 hourly, clonidine 0.05-0.1 mg 8 hour,

H: Direct vasodilators: Hydralazine 25-100 mg 12 hourly, minoxidil 10-50 mg daily.

I: In special situation (e.g. bronchial asthma, DM, CRF etc.): Choice of special drugs that are not contraindicated.

Adjuvant drug therapv:

Aspirin: 75 mg daily. Antiplatelet therapy reducing cardiovascular risk.

Statins: Atorvastatin 40-60 mg daily. Treating hyperlipidaemia can also produce a substantial reduction in cardiovascular risk.

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