Chronic stable angina physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Among patients with chronic stable angina, the physical examination may be asymptomatic or characteristically normal. Patients that present with left ventricular dysfunction are associated with a poorer prognosis than patients who do not present with dysfunction. All patients should be examined carefully for the presence of rales and other signs of heart failure. The majority of patients present with history of either, chest pain or discomfort categorized as: typical or atypical. Typical presentation would include pain or discomfort in the front or anterior precordium. Atypical presentation can be more convoluted in presentation and involve a wide range of symptoms. For example, an atypical patient may present with dyspnea instead of chest pain and this is termed an angina equivalent. In addition to the historical presentation of chest pain or discomfort, the patient history should be extensively evaluated to include an assessment of cardiovascular risk factors. Physical examination may be normal or asymptomatic. In some cases, a physical examination may reveal heart failure. Additional findings can be important in understanding the onset of the condition. For instance, the presence of peripheral vascular disease may be associated with an increased risk of coronary artery disease (CAD).

Physical Examination

• The physical examination may be entirely normal in patients with stable angina pectoris.
• A patient may present with hypertension, a major risk factor for coronary artery disease.
• Examination of the cardiovascular system during ischemia, however, may reveal:

• Elevated blood pressure
• Transient third heart sound (S3 - ventricular filling sound) and fourth heart sound (S4 - atrial filling sound)
• A sustained outward (dyskinetic) systolic movement of the left ventricular apex
• A murmur of mitral regurgitation
• Paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave

• The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular aortic stenosis, cardiomyopathy and pulmonary hypertension).
• Cardiovascular assessment should also include:

• Examination of peripheral arterial pulses
• Evaluation of retinal fundus for vascular changes
• Screening for risk factors of coronary artery disease (CAD)
• Stigmata of genetic dyslipidemia syndromes such as:

• Tendon xanthomas
• Xanthelasma
• Corneal arcus, particularly in patients under 50 years of age

• Since the presence of non-coronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination should include attention to:

• Peripheral arterial pulses
• Auscultation of the carotid arteries for bruits
• Palpation of the abdomen for aneurysm

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)

History and Physical (DO NOT EDIT)

Class I

"1. In patients presenting with chest pain, a detailed symptom history, focused physical examination, and directed risk factor assessment should be performed. With this information, the clinician should estimate the probability of significant CAD (ie, low, intermediate, high). (Level of Evidence: B)"