Angina

Radiation:  Pain secondary to Myocardial ischenia or injury can radiate along medial aspect of left arm, to jaw , shoulders and epigastrium. Pain of Ureteral stones can radiate down to genitals.  Pain of dissecting aneurysm radiates to back.

Different organs or anatomical locations.

Cardiovascular: Angina
Acute myocardial infraction
Pericarditis
Aortic dissection
Gastrointestinal: Reflux esophagitis
Esophageal spasm
Esophageal rupture
Pulmonary: Pneumothroax
Pleuritis/pneumonia
Pulmonary embolus/infarction
Musculoskeletal: Traumatic injury
Costochondritis
Herpes zoster
Somatization: Anxiety

Differential diagnosis

Angina:

Acute myocardial infarction: 

Reflux esophagitis: 

Somatization:  One of the most common office complaints is a primary care setting is chest "pain" or discomfort. The complaint often reflects somatization. A point should be made that not all pain is organic; therefore, the physician should pursue psychosocial stresses which may be the initiator of this problem. 

Pericarditis. Precardiac, sharp, persistent.  Worse in recumbent position Relieved by sitting.

Dissecting aorta. Sharp stabbing pain radiating to back. Asymmetry of pulses.

Chest wall Lesions

Musculo-skeletal injury:  

Pneumothorax: Pain is sudden in onset, localized, sharp, worse on deep breathing and coughing. Associated with shortness of breath.

Pleuritis/pneumonia  Pain is sudden in onset, localized, sharp, worse on deep breathing and coughing. Associated with productive cough, fever and  chills. 

Coronary arterial system.

Regulation of blood flow to myocardium

Patho-physiology of Myocardial ischemia

Myocardial O2 demand exceeds the ability of the coronary arteries to supply oxygenated blood.

"The presence of atherosclerosis is not the same as the risk the disease presents. More people die
with atherosclerosis than die of it! "

Risk factors

HDL: 

LDL: 

Diagnostic strategy

Supplemental testing

We need to consider Exercise test and Coronary angiogram

It would be reasonable to obtain an exercise test and, depending on the result of that test, proceed with a cardiac catheterization. 

One could easily argue, however, given the multiple risk factors and the high prior probability of coronary artery disease, that a negative exercise test may well be considered a false negative and one would go ahead with a Coronary Angiogram anyway. If that is one’ reasoning, then the exercise test would be a waste of time and money.

Drug therapy 

Strategy  (Revisit Pathophysiology to plan a therapeutic option)

Widen this frame for better visualization

Decrease Myocardial Oxygen demand/Coronary artery vasodilatation:  

Protection against Myocardial Ischemia

Beta-blockers and or calcium channel blockers.
If organic nitrate therapy alone was inadequate to control Mr. Solomon’s angina, then the combination of an organic nitrate and beta-blocker or an organic nitrate with a calcium channel antagonist (verapamil, diltiazem, long acting dihydrophyridine derivative) would provide greater protection against ischemia. Triple therapy consisting of an organic nitrate, beta-blocker and calcium channel blocker might also be considered. The short acting dihydropyridine derivatives (nifedipine) have been shown to increase mortality in patients with coronary artery disease and should not be prescribed.

Alter risk factors

Prevent Coronary thrombosis: Aspirin
Since aspirin reduces the risk of heart attack (coronary thrombosis) in patients with coronary artery disease there is a strong indication for daily aspirin (160 mg/day) therapy. Aspirin causes irreversible inhibition of platelet cyclooxygenase, decreased thromboxane A2 production and decreased platelet aggregation. Then aspirin is given as prophylactic therapy to reduce the risk of intracoronary thrombosis and would probably have little effect on Mr. Solomon’s angina.

Options we have to relieve mechanical obstruction of Coronary arteries 

Angioplasty:

Coronary Artery Bypass Surgery