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December 21, 2023 at 1:44 pm #1510AnonymousInactive
Presentation with stable chest pain
Diagnose stable angina based on one of the following:
clinical assessment alone or
clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see table 1), further diagnostic investigation is unnecessary. Manage as angina.
Table 1 Percentage of people estimated to have coronary artery disease according to typicality of symptoms, age, sex and risk factors:
Unable to post the table- shall ask for guidance on how to do this as a table from Dr Badrinath.
For men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
For women older than 70, assume an estimate of 61–90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed.
Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD).
Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre).
Lo = Low risk = none of these three.
The ‘non-anginal chest pain’ columns represent people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely.
If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.
Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal.
Other features which make a diagnosis of stable angina unlikely are when the chest pain is:continuous or very prolonged and/or
unrelated to activity and/or
brought on by breathing in and/or
associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing.
Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
In people without confirmed CAD, in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD (see table 1).
Take the clinical assessment and the resting 12-lead ECG into account when making the estimate.Arrange further diagnostic testing as follows:
If the estimated likelihood of CAD is 61–90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate .
If the estimated likelihood of CAD is 30–60%, offer functional imaging as the first-line diagnostic investigation .
If the estimated likelihood of CAD is 10–29%, offer CT calcium scoring as the first-line diagnostic investigation.
Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.
G Mohan.
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