S2 L2.2: Angina

Question 1

Pain coming from the heart

Answer 1

Angina

Question 2

Pain over the chest

Answer 2

Pectoris

Question 3

Is essentially defined as chest pain

Answer 3

Angina Pectoris

Question 4

T/F: Chest pain can also be felt on the arm because nerves of heart and arm fall into the same nucleus

Answer 4

True

Question 5

What do you call the type of pain that may be referred to the left shoulder, neck, jaw, or between shoulder blades?

Answer 5

Ischemic pain

Question 6

T/F: Angina Pectoris is a superficial visceral pressure pr squeezing sensation

Answer 6

False. It is a DEEP visceral pressure or squeezing sensation

Question 7

T/F: Angina Pectoris is difficult to locate because it is not skin-deep

Answer 7

True

Question 8

T/F regarding angina pectoris:

1. Some describe it as tightness, heaviness, and so,e say there is radiation to the back
2. Some diabetics experience it in stomach
3. Sometimes mistaken for hyperacidity but it is already a heart attack
4. Should not be interpreted as heart attack but as a symptom of a possible heart attack
5. Almost always at the back or epigastrium; at times, substernal

Answer 8

1 - 4: True
5. False because angina pectoris is almost always substernal; at times, at the back or epigastrium

Question 9

Give me the three (3) possible locations that the pain of angina pectoris can radiate to

Answer 9

jaw, neck or arm; typically the ulnar sirface of left arm

Question 10

How many minutes does angina usually occur?

Answer 10

2 - 30 mins. It is typically transient

Question 11

T/F Regarding Angina Pectoris:

1. Precipitated by exertion, emotional upset or other events
   that increase myocardial oxygen demand (tachycardia or HTN)
2. Relieved by rest or cessation of triggering event and
   nitrates
3. Beyond 30 mins it can already be a heart attack
4. May radiate to neck, shoulder, arm

Answer 11

1. T
2. T
3. T
4. T

Question 12

T/F:

Anything that increase myocardial oxygen demands either through physical or emotional/ psychological means as long as there’s bradycardia or blood pressure goes down may indicate angina pectoris which may lead to a heart attack

Answer 12

False

Anything that increase myocardial oxygen demands either through physical or emotional/ psychological means as long as there’s TACHYCARDIA or blood pressure goes UP may indicate angina pectoris which may lead to a heart attack

Question 13

What is the theory of convergence?

Answer 13

Chest pain coming from the heart can also be
felt in the arm because the nerves that supply
the heart and arm end up on the same nucleus
in the dorsal column of the spinal cord

Question 14

What is defined as not typically the chest heaviness, tightness, or squeezing
pain?

Answer 14

Anginal Equivalents

Question 15

Give me the five (5) symptoms of anginal equivalents that are usually in the elderly and diabetics

Answer 15

○ Dyspnea
○ Faintness
○ Fatigue
○ Eructation
■ “Empacho” or indigestion feeling
○ Epigastric pain

Question 16

T/F:

It is okay to sometimes disregard the symptoms of anginal equivalents as these do not usually lead to heart attack

Answer 16

False.

Very important not to disregard these symptoms as these
may lead to heart attack

Question 17

Give me at least (5) symptoms that are unlikely anginal

Answer 17

● Pleuritic pain
● Primary or sole location of discomfort in the middle or
lower abdominal region; if pt can localize if left or right,
the pain is most likely not d/t the heart
● Pain that may be localized at the tip of one finger,
particularly over the left ventricular apex
● Pain reproduced with movement or palpation of the chest
wall or arms
● Constant pain that persists for many hours
● Very brief episodes of pain that last a few seconds or
less (fleeting pain)
● Pain that radiates into the lower extremities, higher than
the jaw or lower than the umbilicus
● Tenderness upon palpation may indicate musculoskeletal
problem
● Pain persists for hours

Question 18

SYMPTOMS UNLIKELY ANGINAL

What symptom is described in the following??

Sharp or knife-like pain brought on by
respiratory movements or cough d/t inflammation on
pleural space

Answer 18

Pleuritic pain

Question 19

The following are symptoms that are unlikely anginal, EXCEPT:

A. Primary or sole location of discomfort in the middle or
lower abdominal region; if pt can localize if left or right,
the pain is most likely not d/t the heart
B. Pain that may be localized at the tip of one finger,
particularly over the left ventricular apex
C. Pain persists for hours
D. Tenderness upon palpation may indicate musculoskeletal
problem
E. None of the above

Answer 19

E

Question 20

Select the letters that are symptoms that are unlikely anginal

A. Constant pain that persists for many hours
B. Deep visceral pressure or squeezing sensation
C. Very brief episodes of pain that last a few seconds or
less (fleeting pain)
D. Precipitated by exertion
E. Pain that radiates into the lower extremities, higher than
the jaw or lower than the umbilicus

Answer 20

A, C, E

B and D are symptoms of angina pectoris

Question 21

T/F regarding symptoms unlikely anginal:

1. Pain reproduced with movement or palpation of the chest or arms may be musculoskeletal
2. If pain is fleeting, it is possibly cuased by a muscle

Answer 21

1. True. Because if it’s angina the
   pain should be present regardless movement or
   position
2. True. If it’s the heart it is usually in a crescendo (pain goes
   higher) manner as you go on with your activity
   (physically or emotionally)

Question 22

Give me the six (6) differential diagnosis if pain is RETROSTERNAL

Answer 22

1. Myocardial ischemic pain
2. Pericardial pain
3. Esophageal pain
4. Aortic dissection
5. Mediastinal lesions
6. Pulmonary embolization

Question 23

Give me the four (4) differential diagnosis if pain is INTERSCAPULAR

Answer 23

1. Myocardial ischemic pain
2. Musculoskeletal pain
3. Gallbladder pain
4. Pancreatic pain

Question 24

Give me the three (3) differential daignosis if pain is in the ARMS

Answer 24

1. Myocardial ischemic pain
2. Cervical/dorsal spine pain
3. Thoracic outlet syndrome

Question 25

The following are differential diagnosis if pain is in the right anterior chest, EXCEPT: A. Gallbladder pain B. Distention of the liver C. Subdiaphragmatic abscess D. Pneumonia/pleurisy E. Injuries F. None of the Above

Answer 25

F. The following are the rest of the differential diagnosis if pain is in the RIGHT ANTERIOR CHEST: - Gastric or duodenal penetrating ulcer - Pulmonary embolizaation - Acute myosistis

Question 25

Give me the seven (7) differential diagnoses if the pain is felt in the SHOULDER

Answer 25

- Myocardial ischemic pain - Pericarditis - Subdiaphragmatic abcess - Diaphragmatic pleurisy - Cervical spine disease - Acute musculoskeletal pain - Thoracic outlet syndrome

Question 25

Select the letters that are included in the differential diagnosis if the pain is in the EPIGASTRIC region: A. Myocardial ischemic pain B. Pericardial pain C. Esophageal pain D. Duodenal/gastric pain E. Pancreatic pain F. Galbladder pain G. Distention of the liver H. Diaphragmatic pleurisy I. Pneumonia

Answer 25

All are included

Question 26

Give me the nine (9) differential diagnoses if the pain is felt in the LEFT LOWER ANTERIOR CHEST

Answer 26

- Intercostal neuralgia - Pulmonary embolization - Myositis - Pneumonia/pleurisy - Splenic infarction - Splenic flexure syndrome - Subdiaphragmatic abscess - Precordial catch syndrome - Injuries

Question 26

Match the following items regarding TYPES OF THRESHOLDS: 1. Patient can predict what level produce angina 2. There are good days and bad days because it is unpredictable 3. Postprandial usually high carbohydrate 4. Tricky for HCPs since pt may have varied answers each time you ask them if they feel chest pain upon climbing the stairs since they may change the level of the activity as they are able to predict what level of exertion causes the angina. A. Fixed threshold Angina B. Variable-threshold Angina C. MIxed Angina

Answer 26

1. A 2. B 3. B ■ Can also happen after a big meal ■ Small circulation going into the splanchnic area bc need to digest a lot of food and that stills blood away from the heart ■ If the heart is already diseased, there’s narrowing of the arteries and taking blood away from the heart will cause angina 4. A

Question 27

Match the following items regarding TYPES OF THRESHOLD: 1. Constant level of activity that causes angina 2. More difficult to manage but easier to identify by doctors 3. Between fixed and variable 4. Circadian variation in angina usually in AM 5. Pt can prevent the occurrence of chest pain because they know at what level of activity the onset of angina begins A. Fixed threshold Angina B. Variable-threshold Angina C. MIxed Angina

Answer 27

1. A 2. B 3. C 4. B 5. A. Thus, patients will adjust their level of activity to not feel the angina

Question 28

T/F Regarding Variable Angina: 1. In the variable angina, it could happen at any time of the day 2. If you’re about to wake up in the morning, catecholamines increase and that would be a time when a diseased heart is more prone to develop angina, heart attack, or stroke due to the catecholamine surge 3. We do not advice high carbohydrate or calorie intake for heart diseased patients

Answer 28

1. False. This kind of threshold coincides with the circadian rhythm of catecholamines As we go on along the day, we need the catecholamines to start our day but in the afternoon or as we end the day, catecholamines decrease and it’s high time for us to rest 2. True 3. True

Question 29

ANGINA GRADING What class is this? and according to what classification? Patients have cardiac disease but without the resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

Answer 29

Class 1 of New York Heart Association Functional Classification

Question 30

ANGINA GRADING What class is this? and according to what classification? Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest

Answer 30

Class 4 of Canadian Cardiovascular Society Functional Classification

Question 31

ANGINA GRADING What class is this? and according to what classification? Patients have cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Answer 31

Class 2 of New York Heart Association Functional Classification

Question 32

ANGINA GRADING What class is this? and according to what classification? Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing more than one flight of stairs in normal conditions.

Answer 32

Class 3 of Canadian Cardiovascular Society Functional Classification

Question 33

ANGINA GRADING What class is this? and according to what classification? Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or when under emotional stress or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions.

Answer 33

Class 2 of Canadian Cardiovascular Society Functional Classification

Question 34

ANGINA GRADING What class is this? and according to what classification? Patients have cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.

Answer 34

Class 3 of New York Heart Association Functional Classification

Question 35

ANGINA GRADING What class is this? and according to what classification? Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina present with strenuous or rapid or prolonged exertion at work or recreation.

Answer 35

Class 1 of Canadian Cardiovascular Society Functional Classification

Question 36

ANGINA GRADING What class is this? and according to what classification? Patients have cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased

Answer 36

Class 4 of New York Heart Association Functional Classification

Question 37

T/F regarding angina grading: 1. New York Heart Association Functional Classification can also be used for patients with heart failure 2. New York Heart Association Functional Classification - usually use this for angina and chest pain 3. Regarding Class 3 of Canadian Cardiovascular Society Functional Classification : Even brushing your teeth or turning on bed. Need to see the doctor ASAP, bc might suffer from a heart attack or you might never recover from it alive 4. NYHA Class 3 = obstruction present in the coronary artery at about >50% or 80% 5. NYHA Class IV = needs hospitalization; can die easily from coughing or standing up

Answer 37

1. T 2. F. Canadian Cardiovascular Society Functional Classification - usually use this for angina and chest pain 3. Regarding Class 4 of Canadian Cardiovascular Society Functional Classification : Even brushing your teeth or turning on bed. Need to see the doctor ASAP, bc might suffer from a heart attack or you might never recover from it alive 4 - 5 True