Ischaemic heart disease may manifest as asymptomatic coronary atherosclerosis, as (stable) angina pectoris and / or as acute coronary syndrome (ACS). ACS comprises instable angina pectoris (IAP) or acute myocardial infarction (AMI).
Angina pectoris (AP) refers to chest symptoms from myocardial ischaemia. Stable AP is characterised by chest tightness or pain, is provoked by physical exercise, emotions or cold, and disappears at rest or with sublingual nitrates within 15 minutes.
In ACS, symptoms are generally more severe and rest or nitrates do not completely resolve the symptoms. In IAP, myocardial ischaemia occurs progressively at rest or at minimal physical exertion.
In AMI, myocardial necrosis occurs, resulting in biochemical markers of myocardial damage. At least one of the following items is also present: clinical signs of AMI (sudden chest pain or tightness), corresponding abnormalities on the electrocardiogram or at coronary imaging or an identified thrombus in coronary angiography or autopsy.
The most common symptom of ischaemic heart disease in both men and women is chest pain. The pain sometimes radiates to the left arm or shoulder. Other common symptoms are dyspnoea or difficulty breathing. Transpiration, pallor and nausea or vomiting may also occur, especially in ACS. Less common symptoms are interscapular pain, dizziness, neck pain, palpitations, pain in the right arm, shoulder or jaw, dyspepsia, epigastric pain and fatigue. Patients may be anxious or agitated. There is a large variety in the presentation of signs and symptoms, making clinical diagnosis challenging.
If stable AP is suspected, cardiovascular risk factors should be assessed and the patient should be referred to the cardiologist to confirm or reject the diagnosis. Treatment consists of symptom control (nitrates, beta-blockers) and secondary cardiovascular prevention (lifestyle, platelet aggregation inhibitors, statins, blood pressure management).
In patients suspected of having ACS, an urgent referral with ambulance transport is indicated. While waiting for emergency transport, nitrates, fentanyl or morphine may be administered, along with oxygen and platelet aggregation inhibitors.
In hospital, treatment is started to restore oxygen supply to the heart (e.g. percutaneous coronary intervention). Cardiovascular risk management is then initiated.