8. The syndromes of ischemic heart disease and their differential diagnostics (DDx of chest pain)

Page created on August 14, 2021. Last updated on April 19, 2022 at 09:28

Syndromes of ischaemic heart disease

Ischaemic heart disease includes the following syndromes:

• Acute coronary syndrome (ACS)
  • ST elevation myocardial infarction (STEMI)
  • Non-ST elevation ACS (NSTE-ACS)
    • Non-ST elevation myocardial infarction (NSTEMI)
    • Unstable angina (UA/UAP)
• Chronic coronary syndrome (CCS)
  • Effort angina/stable angina
  • CCS with “anginal equivalent”
  • Vasospastic angina/Prinzmetal angina
  • Silent ischaemia

Over time, CCS can cause ischaemic cardiomyopathy, leading to heart failure, or it can progress to ACS. ACS syndromes are described in topic 9.

Effort angina

Effort angina, also called stable angina, is the classical manifestation of CCS. It’s characterised by anginal pain which occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerine. It occurs when the atherosclerotic stenosis reaches > 70% of the coronary artery lumen.

Anginal equivalents

Not all patients with CCS experience the typical anginal chest pain. Some experience so-called “anginal equivalents”, dyspnoea, nausea, sweating, or fatigue.

Vasospastic angina

Some patients with CCS experience spontaneous and transient symptoms (angina or anginal equivalent) in rest. This is called vasospastic angina and is due to coronary artery vasospasm, with or without underlying coronary artery disease.

ST elevation or depression is present during the pain episode. This may make it difficult to distinguish from ACS. Patients where ACS can’t be ruled out should be managed as ACS. Vasospasm can be diagnosed on angiography, and angiography is usually required to rule out ACS in these patients.

Silent ischaemia

Some patients with CCS never experience symptoms, called silent ischaemia. This is often due to diabetes neuropathy, but not always.

Types of chest pain

We distinguish three types of chest pain; typical angina, atypical angina, and non-anginal chest pain. There are three features which are important here:

• The pain has typical anginal characteristics: constricting discomfort in the front of the chest or in the neck, jaw, shoulder, or arm
• The pain is provoked by physical or emotional stress
• The pain is relieved by rest or nitroglycerine

Typical angina has all three features. If only 2 features are present, the chest pain is called atypical angina. If only 1 or none of the above apply, it’s called non-anginal chest pain.

As few as 10 – 15% of patients with CCS present with typical angina.

Differential diagnosis of chest pain

See topic 20.