Model Answer
0 min readIntroduction
Central chest pain, particularly in a 60-year-old male with the described characteristics – brought on by exertion, squeezing in nature, radiating to the left arm, and relieved by rest – is highly suggestive of angina pectoris, a symptom of underlying coronary artery disease (CAD). CAD is a leading cause of morbidity and mortality globally. Prompt and accurate evaluation is crucial to determine the severity of the condition and initiate appropriate treatment to prevent adverse cardiovascular events like myocardial infarction (MI) or unstable angina. This case necessitates a thorough assessment to differentiate between stable angina, unstable angina, and other potential causes of chest pain.
Initial Assessment & History Taking
A detailed history is paramount. Beyond the presenting symptoms, inquire about:
- Risk factors for CAD: Hypertension, hyperlipidemia, diabetes mellitus, smoking history, family history of premature CAD.
- Characteristics of pain: Onset, duration, location, radiation, character (squeezing, crushing, burning), severity (using a pain scale), aggravating and relieving factors.
- Associated symptoms: Dyspnea, palpitations, nausea, sweating, dizziness.
- Past medical history: Previous cardiac events, other medical conditions, medications.
Physical Examination
A focused physical examination should include:
- Vital signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
- Cardiovascular examination: Auscultation for murmurs, gallops, or rubs. Palpation for heaves or thrills. Assessment of peripheral pulses.
- Respiratory examination: Auscultation for crackles or wheezes.
- General examination: Looking for signs of peripheral edema or other systemic illnesses.
Investigations
The following investigations are crucial for evaluation:
1. Electrocardiogram (ECG)
An ECG should be performed immediately to look for signs of ischemia (ST-segment depression or elevation, T-wave inversion) or previous MI. A normal ECG does not rule out ACS.
2. Cardiac Biomarkers
Serial measurements of cardiac troponin I or T are essential to detect myocardial damage. Elevated troponin levels indicate MI.
3. Complete Blood Count (CBC) & Basic Metabolic Panel (BMP)
To assess overall health and rule out other causes of chest pain (e.g., anemia, electrolyte imbalances).
4. Lipid Profile
To assess cholesterol levels and risk for CAD.
5. Chest X-ray
To rule out other causes of chest pain, such as pneumonia, pneumothorax, or aortic dissection.
6. Non-invasive Cardiac Testing (if ECG and biomarkers are negative)
- Stress Test: Exercise stress test or pharmacological stress test (using dobutamine or adenosine) to assess for inducible ischemia.
- Echocardiogram: To assess left ventricular function and wall motion abnormalities.
- Coronary Computed Tomography Angiography (CCTA): To visualize the coronary arteries and detect stenosis.
7. Invasive Coronary Angiography (if high risk or non-invasive tests are positive)
The gold standard for diagnosing CAD. It allows for visualization of the coronary arteries and potential intervention (PCI – percutaneous coronary intervention) if significant stenosis is present.
Treatment
Treatment depends on the diagnosis:
1. Acute Coronary Syndrome (ACS) – Unstable Angina or MI
- Immediate: Oxygen, Aspirin (300mg), Nitroglycerin (sublingual or IV), Morphine (for pain relief), Beta-blockers (if not contraindicated).
- Further Management: Antiplatelet therapy (clopidogrel, ticagrelor, or prasugrel), anticoagulation (heparin or enoxaparin), and urgent coronary angiography with possible PCI or CABG (coronary artery bypass grafting).
2. Stable Angina
- Lifestyle Modifications: Smoking cessation, weight loss, healthy diet, regular exercise.
- Medical Therapy: Beta-blockers, calcium channel blockers, nitrates, ranolazine.
- Revascularization: PCI or CABG may be considered if medical therapy is insufficient.
3. Other Causes of Chest Pain
Treatment will be directed towards the underlying cause (e.g., antibiotics for pneumonia, pain management for musculoskeletal pain).
Conclusion
This case presentation strongly suggests angina pectoris, necessitating a prompt and thorough evaluation to rule out ACS. A systematic approach involving detailed history taking, physical examination, and appropriate investigations is crucial. Treatment strategies range from lifestyle modifications and medical therapy for stable angina to urgent revascularization for ACS. Long-term management focuses on risk factor modification and secondary prevention to reduce the risk of future cardiovascular events. Continuous monitoring and patient education are essential components of care.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.