Angina Pectoris and Aortic Dissection Overview

Angina Pectoris

• Cause: Typically due to atherosclerotic coronary artery disease and severe obstruction. Risk factors include smoking, diabetes, hypertension, high cholesterol, and family history.
• Stable Angina: Characterized by episodic chest pressure, triggered by exertion or stress, and relieved by rest or nitrates. Its onset and resolution are predictable.
• Unstable Angina: Can occur with less exertion or even at rest. Unpredictable onset and resolution.
• Symptoms (Possible): Transient S4, S3, mitral murmur, and paradoxically split S2 with pain.
• Diagnosis: Based on patient history and stress tests; confirmed by coronary angiography. ECG is usually normal between episodes, potentially showing ST depression during episodes.

Aortic Dissection

• Demographics: Most common in patients aged 50-70. Risk factors include hypertension, Marfan syndrome, bicuspid aortic valve, coarctation of the aorta, and pregnancy.
• Types: Type A affects the ascending aorta or arch; Type B does not.
• Symptoms: Sudden onset chest pain, radiating to the interscapular region. Unequal blood pressures in upper extremities, and a new diastolic murmur of aortic insufficiency (occasionally in Type A).
• Diagnosis: Chest X-ray (nearly always abnormal); ECG typically normal unless the coronary arteries are compromised. CT, transesophageal echocardiography, MRI, or aortography usually confirm the diagnosis.

Atrial Fibrillation

• Description: The most frequent chronic arrhythmia.
• Causes: Including mitral valve disease, hypertension, ischemic heart disease, dilated cardiomyopathy, alcohol use, hyperthyroidism, pericarditis, and cardiac surgery (and idiopathic cases).
• Complications: Precipitation of cardiac failure and arterial embolization.
• Symptoms (Possible): Palpitations, dyspnea, chest pain (often asymptomatic).
• ECG Findings: Irregularly irregular heartbeat; variable intensity S1; Occasional S3; no/absent S4. Ventricular rates of 80-170/min (untreated) Wider QRS and antegrade conduction through the pathway, if with an accessory pathway.
• Diagnosis: ECG to determine the ventricular rate (80-170 beats/minute), check for accessory pathway.

Atrial Septal Defect

• Presentation: Small defects are usually asymptomatic.
• Large defects: Individuals with large defects often experience symptoms (exertional dyspnea, fatigue, palpitations) possibly by age 40.
• Complications: Paradoxical embolism is possible (upper or lower extremity venous thrombus embolizing to the brain or extremity rather than the lung).
• Symptoms (Possible): Right ventricular lift; widened and fixed splitting of S2; systolic flow murmur in the pulmonary area.
• Diagnosis: Echo Doppler with agitated saline contrast injection, radionuclide angiogram, or cardiac catheterization to assess the QP:QS ratio (pulmonary flow to systemic flow).
• ECG Findings: Right ventricular hypertrophy and right axis deviation (ostium secundum). Left anterior hemiblock (ostium primum); complete/incomplete right bundle brunch block in 95% of cases.

Congestive Heart Failure

• Types: Systolic dysfunction (reduced ability to pump, decreased ejection fraction) and diastolic dysfunction (impaired relaxation, normal ejection fraction).
• Causes (Systolic): Coronary artery disease, dilated cardiomyopathy, myocarditis, hypertension.
• Causes (Diastolic): Ischemia, hypertension, aortic stenosis, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and small-vessel disease.
• Symptoms (Left-sided failure): Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulsus alternans, rales, gallop rhythm; pulmonary venous congestion on chest X-ray.
• Symptoms (Right-sided failure): Fatigue, malaise, elevated venous pressure, hepatomegaly, abdominojugular reflux, and dependent edema .

Prinzmetal's Angina

• Cause: Intermittent focal spasm of a normal coronary artery.
• Associated Conditions: Migraine, Raynaud's phenomenon.
• Pain Characteristics: Pain similar to angina, often severe and occurring at rest.
• Demographics: More common in women under 50, and often occurs in the early morning.
• ECG Findings: ST segment elevation, but normal enzyme studies.
• Diagnosis: Confirmed by ergonovine challenge during cardiac catheterization.