EpistemisAtypical coronary ischemic pain
Specialty: Cardiovascular.
Why it occurs
- Obstructive ischemic heart disease (manifested atypically in women, the elderly or diabetics)
- Microvascular coronary spasm (microvascular angina or cardiac syndrome X)
- Coronary vasospasm angina (Prinzmetal's Angina)
- Silent myocardial ischemia associated with diabetic cardiac autonomic neuropathy
- Acute myocardial ischemia in the context of severe anemia or critical aortic stenosis (functional angina)
Initial workup
12-lead electrocardiogram to look for transient ST segment depression or elevation, or T wave inversion during the pain episode; Serial determination of highly sensitive troponin I or T upon admission and 2-3 hours later; Transthoracic Doppler echocardiogram to look for alterations in segmental contractility at rest; Angiotomography of coronary arteries or invasive coronary angiography if the clinical risk is moderate-high or the functional tests are doubtful.
red flags
Presence of pain in the epigastrium of an oppressive, burning or heavy nature, or pain located exclusively in the jaw, neck, right shoulder or interscapular region, triggered by physical effort or emotional stress and that subsides with rest or nitrates, or the sudden appearance of unexplained dyspnea or extreme fatigue as the only symptom of effort. If it is associated with cold diaphoresis, nausea, vomiting, presyncope or hypotension, acute coronary syndrome should be suspected and immediately referred for an electrocardiogram and troponins.
Standard management
- Acetylsalicylic acid — antiplatelet agent indicated for prophylaxis of coronary thrombotic events; 100 mg per day orally
- Sublingual nitroglycerin — coronary vasodilator indicated to relieve acute anginal pain; 0.4 mg sublingual per dose, repeatable every 5 minutes up to a maximum of 3 doses, discontinuing if SBP <90 mmHg
- Atenolol — beta blocker indicated to reduce myocardial oxygen demand by reducing heart rate and contractility; 25 to 50 mg once daily orally
- Atorvastatin (statin indicated to reduce cardiovascular risk by stabilizing coronary plaque; 40 to 80 mg per day orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 5
- Treatment options
- 4