Monday, November 4, 2013

Differential Diagnosis of Causes of Angina Besides Coronary Artery Disease

There are othe cardiac causes of angina besides coronary artery disease:

A. Congenital anomalies of the coronary arteries can take many forms. Their prevalence is 1% to 2% of the general population. Anomalous origin of the left or right coronary artery from the contralateral sinus of valsava with passage between the aorta and pulmonary artery may produce ischemia and is associated with sudden death.

B. Myocardial bridge is usually benign but may be associated with ischemic symptoms. The bridging occurs most commonly in the left anterior descending artery. Beta-adrenergic antagonists are helpful to increase diastolic filling. but nitrates can excerbate the angina. A coronary stent may be indicated in the appropriate circumstances.

C. Coronary Arteritis is associated with collagen vascular disease such as lupus, polyarterteritis nodusa, and scleroderma.

D. Coronary Artery Ectasia is characterized by irregular, diffuse, fusiform dilatation of coronary arteries. Thrombus and obstructive lesions may be associated with these fusiform dilatations. This is most commonly due to hypertension.

E. Radiation Therapy may produce coronary arterial fibrosis with intimal proliferation. This evolves at a variable time course and may lead to ischemia.

F. Cocaine is associated with vasospasm and thrombus formation, which can produce ischemia, cocaine also causes endothelial dysfunction and hastens the development of atherosclerosis, which can produce angina.

G. Aortic Stenosis causes angina by subendocardial ischemia due to wall stress.

H. Hypertrophic Cardiomyopathy causes subendocardial ischemia by a mechanism similiar to aortic stenosis.

I. Prinzmetal's Angina, or Vasospastic Angina, is well-recognized syndrome in which patients present with resting angina and ST-segment elevation. Variant angina is usually associated with an underlying noncritical stenosis; however, a subtantial percentage of patients have no evidence of underlying stenosis. This may be due to spasm of the artery, particularly around the area of noncritical stenosis. Coronary artery spasm may be provoked by infusion of dopamine, acetylcholine, or ergonovine.

J. Syndrome X is typical anginal pain in the setting of normal coronary arteries. Patients may have angiographic stenoses, but these are inadequate to else coronary blood flow with exercise. Abnormalities in Coronary vasomotor tone may mediate angina, resulting in "microvascular angina" - that is, defective endothelial-derived dilattion of the coronary microcirculation. Evidence for myocardial ischemia in syndrome X patients manifests as reversible perfusion defects with thallium scintigraphy and magnetic resonance imaging (MRI) or transient impairment of global or regional ventricular function on echocardiography.


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