C h a p t e r 1 9
Disorders of Cardiac Function
455
classifications: chronic stable angina, silent myocardial
ischemia, and variant or vasospastic angina.
Chronic Stable Angina
Angina pectoris is a symptomatic paroxysmal chest pain
or pressure sensation associated with transient myocar-
dial ischemia. Chronic stable angina is associated with
a fixed coronary obstruction that produces an imbal-
ance between coronary blood flow and the metabolic
demands of the myocardium. Stable angina is the initial
manifestation of ischemic heart disease in approximately
half of persons with CAD.
21,22
Although most persons
with stable angina have atherosclerotic heart disease,
angina is not a clinical manifestation in a considerable
number of persons with advanced coronary atheroscle-
rosis. Some persons may not report severe pain, perhaps
because they are physically inactive, have collateral cir-
culation, or do not feel pain due to neuropathy.
Angina pectoris usually is precipitated by situations
that increase the work demands of the heart, such as
physical exertion, exposure to cold, and emotional
stress. The pain is typically described as a steady con-
stricting, squeezing, or a suffocating sensation, increas-
ing in intensity only at the onset and end of the episode.
This pain is commonly located in the precordial or sub-
sternal area of the chest; it is similar to sensations associ-
ated with myocardial infarction in that it may radiate to
the left shoulder, jaw, arm, or other areas of the chest or
back (Fig. 19-11). In some persons, the arm or shoulder
pain may be confused with arthritis; in others, epigastric
pain is confused with indigestion. Angina commonly is
categorized according to whether it occurs with physi-
cal activity, occurs during rest, is of new onset, or is of
increasing severity.
Typically, chronic stable angina is provoked by exer-
tional activity or emotional stress and relieved within
minutes by rest or by nitroglycerin. A delay of more
than 5 to 10 minutes before relief is obtained suggests
that the symptoms result from severe ischemia. Angina
that occurs at rest, is of new onset, or is increasing
in intensity or duration denotes an increased risk for
myocardial infarction and should be evaluated using the
criteria for ACS.
Left ventricle
Right ventricle
Aneurysm
FIGURE 19-10.
Paradoxical movement of a left ventricular
aneurysm during systole.
FIGURE 19-11.
Areas of pain due to Angina including anterior and posterior views.
