V. STABLE AND UNSTABLE ANGINA
There are two types of angina: stable and unstable. Angina is described as stable if the condition has been present for more than two months, or if there has been no change in the pattern of pain, particularly no change in the frequency of attacks, severity, or duration of pain. Patients with stable angina only get pain at rest with sudden emotional stress. Angina is described as unstable when angina is present for less than 60 days, or when there is an increase in the frequency, severity, and duration of pain and a change in the known precipitating factors. If pain that normally occurs only on exertion or moderate activities starts to occur on minimal activity or at rest but without emotional stress, a patient should seek urgent attention in the emergency room.
A. Case History
A 54-year-old man was late for a job interview. With some difficulty, he found a parking space. It was a very cold and windy January day, and he walked quickly for about two hundred yards toward the building. Suddenly, he felt a strange sensation in his chest. He kept on walking, but about a minute later the discomfort felt like a heavy weight on his breastbone. His chest felt tight as he reached the building, and he rested against the wall. He took a few deep breaths and felt better after about one minute. He had his job interview without any further discomfort and remained pain-free until a few months later when, while walking up an incline, he felt a similar pain. Again he had to stop for a minute or two to get relief from the strange feeling of suffocation or strangulation that accompanied the tight feeling in his upper chest. The next day he was able to walk about a mile at a normal pace on a level grade without chest discomfort. A few days later he went golfing. During the first nine holes he felt well and had no chest discomfort, but walking upslope on the long 11 hole, he felt pressure in his chest, a tightness across the shoulder, and a heaviness in his arms. He stopped pulling his golf cart and stood still for a minute. Somewhat embarrassed for holding up the game, he searched his golf bag for some antacid tablets but, as he opened the package, he noticed the pain had completely gone. He felt well that night. The next day when he walked quickly the discomfort returned. His wife insisted on a visit to the doctor. The doctor found him to be slightly overweight with a normal ECG reading. He was given nitroglycerin to be used under the tongue and an oral nitrate called isosorbide dinitrate in tablet form to help dilate the coronary arteries and relieve pain.