A sixty-year-old male develops central chest pain while walking uphill. The pain is squeezing in character, radiating to left arm, that relieves on taking rest. Discuss in short about the evaluation and treatment of this case.

I. History Taking & Physical Examination

A detailed history is paramount. Beyond the presenting complaint, inquire about:

• Risk factors for CAD: Hypertension, hyperlipidemia, diabetes mellitus, smoking history, family history of premature CAD, obesity, sedentary lifestyle.
• Characteristics of the pain: Onset, duration, location, radiation, character (squeezing, crushing, burning), aggravating and relieving factors.
• Associated symptoms: Dyspnea, palpitations, nausea, sweating, dizziness.
• Past medical history: Previous cardiac events, other comorbidities.
• Medications: Current medications, allergies.

Physical examination should include:

• Vital signs: Blood pressure, heart rate, respiratory rate, temperature.
• Cardiovascular examination: Auscultation for murmurs, gallops, or rubs. Palpation for heaves or thrills. Assessment of peripheral pulses.
• Pulmonary examination: Auscultation for crackles or wheezes.
• General examination: Looking for signs of peripheral vascular disease or other relevant conditions.

II. Investigations

Investigations are crucial to confirm the diagnosis and assess the severity of CAD.

• Electrocardiogram (ECG): To detect any acute ischemic changes or arrhythmias. A normal ECG does not rule out CAD.
• Cardiac biomarkers (Troponin I/T): To rule out myocardial infarction. Serial measurements may be needed.
• Complete Blood Count (CBC): To assess for anemia or infection.
• Lipid profile: To assess cholesterol levels.
• Fasting blood glucose/HbA1c: To assess for diabetes.
• Chest X-ray: To rule out other causes of chest pain, such as pneumonia or pneumothorax.
• Echocardiogram: To assess left ventricular function and wall motion abnormalities.
• Stress testing: Exercise stress test, stress echocardiogram, or nuclear stress test to assess for inducible ischemia.
• Coronary angiography: The gold standard for diagnosing CAD. Indicated if stress test is positive or if the patient is high risk.

III. Diagnosis

Based on the history, physical examination, and investigations, a diagnosis of stable angina pectoris is likely. However, it’s essential to differentiate it from other conditions causing chest pain, such as:

• Unstable angina/Non-ST-elevation myocardial infarction (NSTEMI): Characterized by new-onset angina, angina at rest, or increasing angina. Requires urgent hospitalization and management.
• ST-elevation myocardial infarction (STEMI): Requires immediate reperfusion therapy (thrombolysis or percutaneous coronary intervention - PCI).
• Pericarditis: Typically sharp, pleuritic chest pain relieved by sitting up and leaning forward.
• Esophageal spasm: Can mimic angina.
• Musculoskeletal chest pain: Often reproducible with palpation.

IV. Treatment

Treatment aims to relieve symptoms, prevent progression of CAD, and reduce the risk of cardiovascular events.

A. Acute Management (if stable angina)

• Sublingual nitroglycerin: For immediate relief of angina.
• Aspirin: 75-150mg daily, unless contraindicated.

B. Long-Term Management

• Lifestyle modifications: Smoking cessation, healthy diet (low in saturated fat and cholesterol), regular exercise, weight management, stress reduction.
• Pharmacological therapy:
  • Beta-blockers: Reduce heart rate and blood pressure, decreasing myocardial oxygen demand.
  • Calcium channel blockers: Dilate coronary arteries and reduce blood pressure.
  • Nitrates: Long-acting nitrates can be used for prophylaxis.
  • Statins: Lower cholesterol levels and stabilize plaques.
  • ACE inhibitors/ARBs: For patients with hypertension, diabetes, or left ventricular dysfunction.
  • Dual Antiplatelet Therapy (DAPT): May be considered after PCI.
• Revascularization: PCI (angioplasty and stenting) or coronary artery bypass grafting (CABG) may be considered for patients with significant CAD, especially if medical therapy is inadequate.