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Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

Daniel Lee Kulick, MD, FACC, FSCAI

Daniel Lee Kulick, MD, FACC, FSCAI

Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Diagnosis and treatment tend to occur at the same time in patients who are experiencing chest pain. If there is concern that heart muscle is at risk, delays need to be minimized so that blood supply to that muscle can be restored.

Medical History

The diagnosis of angina is made by history of the patient. If the story that the patient tells is suggestive of cardiac ischemia (cardiac= heart + ischemia= decreased blood supply), then the health care practitioner will continue on the path to determine whether a heart attack has occurred.

Important questions include:

1. When did the pain start?
2. What were you doing?
3. Did you have to stop?
4. Did the pain get better with rest?
5. Did the pain come back with activity?
6. Did the pain stay in your chest or did it move somewhere else, like the jaw, teeth, arm or back?
7. Did you get short of breath?
8. Did you become nauseous?
9. Were you sweating profusely?

The medical history also includes assessing risk factors for heart disease, including:

• smoking,
• hypertension or high blood pressure,
• high cholesterol,
• diabetes,
• previous history of other blood vessel problems such as stroke or peripheral vascular disease, and/or
• a family history of heart disease, especially at an early age.

Questions may be asked about changes in exercise tolerance that might provide clues as to whether heart disease is present:

1. Have there been episodes of previous chest pain?
2. Is there shortness of breath on exertion?
3. Can you walk to get the mail?
4. Can you climb a flight of stairs?

The questions may try to distinguish between stable angina and unstable angina. Stable angina tends to be predictable. For example, it may occur after climbing a flight of stairs or walking a couple of blocks and then resolves quickly with rest. Unstable angina may occur without warning when the body is at rest and the heart is not stressed, for example while sitting or sleeping.

Anginal symptoms that change and occur with less activity or sound unstable are worrisome and may be due to increased narrowing of a coronary artery.

Since other diagnoses will be considered, some questions may be asked to identify potential symptoms of conditions such as reflux esophagitis (GERD), gastritis, trauma, pulmonary embolus (blood clot in the lung), or pneumonia.

Physical examination

While the diagnosis is based on history, the physical exam can give some clues.

• Are the blood pressure and pulse rate normal?
• Do the lungs sound clear?
• Are there findings suggestive of an infection (pneumonia) or fluid (edema)?
• Are there unusual heart sounds? New murmurs can be associated with heart attack.
• Are bruits (noises produced by narrowed blood vessels that are heard with a stethoscope) present when listening to the neck, abdomen, or groin?
• Is there tenderness in the abdomen that would suggest the chest pain is due to gallbladder, pancreas, or ulcer disease?

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