Ischemic Heart Disease: Ischemic Heart Disease

CLINICAL PRESENTATION - ISCHEMIC HEART DISEASE

Many episodes of ischemia do not cause anginal symptoms ( silent ischemia). Patients often have a reproducible pattern of pain or other symptoms that appear after a specific amount of exertion. Increased frequency, severity, duration, and symptoms at rest suggest an unstable pattern that requires immediate medical evaluation.
Symptoms may include a sensation of pressure or burning over the sternum or near it, which often radiates to the left jaw, shoulder, and arm. Chest tightness and shortness of breath may also occur. The sensation usually lasts from 30 seconds to 30 minutes.
Precipitating factors include exercise, cold environment, walking after a meal, emotion upset, fright, anger, and coitus. Relief occurs with rest and within 45 seconds to 5 minutes of taking nitroglycerin.
Patients with variant or Prinzmetal's angina secondary to coronary spasm are more likely to experience pain at rest and in the early morning hours. Pain is not usually brought on by exertion or emotional stress nor relieved by rest; the ECG pattern is that of current injury with ST-segment elevation rather than depression.
Unstable angina is stratified into categories of low, intermediate, or high risk for short-term death or nonfatal MI. Features of high-risk unstable angina include (but are not limited to):

Accelerating tempo of ischemic symptoms in the preceding 48 hours.
Pain at rest lasting more than 20 minutes.
age greater than 75 years.
ST-segment changes
Clinical findings of pulmonary edema, mitral regurgitation, S3, rales, hypotension, bradycardia, or tachycardia.

Episodes of ischemia may also be painless, or silent in at least 60% of patients, perhaps due to a higher threshold and tolerance for apin than in patients who have pain more frequently.