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Coronary artery stenoses frequently cause chest pain and/or dyspnoea. The clinical challenge for a physician taking care of patients presenting for the first time with such symptoms is to find out the underlying cause by applying a straightforward and accurate diagnostic approach—which minimises use of personal and financial resources while achieving a conclusive and clinically helpful diagnosis. Since (1) the clinical picture of patients presenting with symptoms of chest pain and/or dyspnoea is multifaceted, and (2) the diagnostic armamentarium for work-up of suspected coronary artery disease (CAD) is steadily growing, an evidence based and profound knowledge of the diagnostic value and specific features/requirements of diagnostic tests is mandatory in order to choose the appropriate modality for the individual patient. Therefore, this article will focus of the pre-test assessment of clinical symptoms in patients with suspected CAD, and the subsequent selection of the most appropriate diagnostic modality for work-up of CAD.
Definition of clinical symptoms
In simple terms, the symptom ‘angina pectoris’ (AP)—and/or the possible equivalent ‘dyspnoea’—occurs as the result of a mismatch between myocardial oxygen demand and supply; for example, it may be caused by an epicardial coronary artery stenosis leading to myocardial ischaemia in the respective myocardial territory distal to the stenosis. In a patient with ‘typical’ symptoms of AP, the discomfort is located retrosternally and occurs during exercise, since the aforementioned mismatch in oxygen demand/supply is increased in response to physical activity and is relieved either by stopping exercise or by administering vasodilating substances such as glyceryl trinitrate (nitroglycerine).1 In contrast, ‘atypical’ AP is defined as chest discomfort fulfilling two out of three conditions associated with ‘typical’ angina. If only one or none of these conditions is met, this is termed ‘non-anginal’ chest pain. ‘Atypical’ angina comprises retrosternal chest pain which occurs at rest and responds to acute nitrates. The clinical …
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