As the nation's #1 killer, it makes sense that CHD would take up more space on this website and it does.  However, I am a psychiatrist and have little need to learn how to treat serious heart disease.  As you will see from this website, prevention is what is most important to me.  After all, I don't want my patients to have a heart attack.

Heart Attacks and Deaths Decreased; Angina Increased: In a study of adults ages 40-50 randomly selected from 24 British towns, researchers documented an annual rate of decrease in heart attacks of 3.6% from 1980 to 2000, but an annual rate of increase in angina of 2.6%. Deaths from heart disease fell by 50%. BMJ  2005;330:1046 (7 May)

Diagnosis

Heart Attack Diagnosis: Non-ST non-Q wave heart attacks: Specific patterns of ST depression are highly predictive of myocardial infarction. For example, ST depression of 4 mm or more in any lead except aVR is 97% specific for myocardial infarction, and isolated depression of 1 mm or more measured at 80 ms of the J point in six or more leads is 96.5% specific for myocardial infarction. The artery responsible for myocardial infarction is the circumflex in around 17% of patients. Less than half of these patients will show ST elevation on a standard 12 lead electrocardiogram and a third will show isolated ST depression. WHO=must have typical history & Q waves & CPK double max (2 of these 3), but cardiac toponin levels show many attacks missed. patients who have a Q wave myocardial infarction, whereas rates of reinfarction, recurrent ischaemia, and long term mortality appear to be higher following non-Q myocardial infarction. BMJ 2/19/02

Pain Presentations: Chest pain was assessed as coronary in 43 (18 females, 25 males, mean age 63 years) and noncoronary in 49 (30 females, 19 males, mean age 62 years) patients. Only few cause-related differences in the symptoms were found. In patients with a coronary cause, the location of chest pain was more often retrosternal (93% vs. 71%, p = 0.0078), in the right arm (23% vs. 6%, p = 0.0186), and less often in the back (28% vs. 51%, p = 0.0241) than in patients with a noncoronary cause of chest pain. Coronary patients more often had a pressing pain quality (81% vs. 61%, p = 0.034), less often pain precipitated by respiration (16% vs. 45%, p = 0.0032), and vertigo (21% vs. 43%, p = 0.0252) than noncoronary patients. The women were older than the men (mean age 65.6 vs. 59.0 years, p = 0.01). Women with a coronary cause more often had a gradual pain onset (78% vs. 48%, p = 0.0488) and relief by rest (78% vs. 40%, p = 0.0139) than men with a coronary cause. Linguistic analysis revealed that men presented themselves as interested in the cause of the chest pain, observing and describing pain concretely, whereas women presented themselves as prevailingly pain enduring, describing their pain diffusely. Vienna. Chest pain in hospitalized patients: cause-specific and gender-specific differences. Vodopiutz J, Poller S, Schneider B, Lalouschek J, Menz F, Stollberger C. J Womens Health (Larchmt) 2002 Oct;11(8):719-27

Atypical Presentation Common: 4,167 randomly sampled Medicare patients hospitalized with unstable angina. Typical presentation as (1) chest pain located substernally in the left or right chest, or (2) chest pain characterized as squeezing, tightness, aching, crushing, arm discomfort, dullness, fullness, heaviness, pressure, or pain aggravated by exercise or relieved with rest or nitroglycerin. Atypical presentation was defined as confirmed UAP without typical presentation. Among patients with confirmed UAP, 51.7% had atypical presentations. The most frequent symptoms associated with atypical presentation were dyspnea (69.4%), nausea (37.7%), diaphoresis (25.2%), syncope (10.6%), or pain in the arms (11.5%), epigastrium (8.1%), shoulder (7.4%), or neck (5.9%). Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Canto JG, Fincher C, Kiefe CI, Allison JJ, Li Q, Funkhouser E, Centor RM, Selker HP, Weissman NW. Am J Cardiol 2002 Aug 1;90(3):248-53

MI Presentation: In 589 AMI pts, chest pain (83.2%), chest pressure or discomfort (67.6%), sweating (64.2%), fatigue (62.6%), dyspnea (60.3%), and arm or jaw pain (58.2%). After adjusting for age, diabetes mellitus, and gender, and relative to non-Hispanic whites, Mexican Americans were more likely to report chest pain, upper back pain, and palpitations, and less likely to report arm or jaw pain. Likewise, relative to men, women were more likely to report fatigue, dyspnea, dizziness, upper back pain, palpitations, and cough, and were less likely to report chest pain. Am J Cardiol 1998 Dec 1;82(11):1329-32; probability of MI, and their associated likelihood ratios (LRs), are new ST-segment elevation (LR range, 5.7-53.9); new Q wave (LR range, 5.3-24.8); chest pain radiating to both the left and right arm simultaneously (LR, 7.1); presence of a third heart sound (LR, 3.2); and hypotension (LR, 3.1). The most powerful features that decrease the probability of MI are a normal ECG result (LR range, 0.1-0.3), pleuritic chest pain (LR, 0.2), chest pain reproduced by palpation (LR range, 0.2-0.4), sharp or stabbing chest pain (LR, 0.3), and positional chest pain (LR, 0.3). JAMA 1998 Oct 14;280(14):1256-63

MI Presentation: 278 ER chest pain patients, 100 individuals had myocardial infarctions (MI), 47 had unstable angina, 25 had stable angina and 106 patients had a non-coronary disease. The twelve most sensitive items for distinguishing MI from other conditions were the following: sudden onset of pain (70%); duration of more than 60 min (88%); constriction and squeezing (79%); oppression (75%); prior anginal attacks (61%); sex male (72%); age over 60 years (74%); abnormal heart auscultation (62%); abnormal electrocardiogram (ECG) (98%); segment (ST) disturbances (86%); increased glucose level (77%); CKMB fraction greater than 6% of total creatine kinase (CK) level (63%). Among the twelve most specific items, also with the best positive predictive value, irradiation in the right arm is of most importance; among the 51 patients with right arm involvement, 48 suffered from a coronary disease and 41 from a myocardial infarction. The largest extension of pain was reported in the latter group. It is concluded that chest pain with a wide irradiation involving the right arm strongly suggests that a myocardial infarction is ongoing. J Intern Med 1990 Mar;227(3):165-72

Sudden Growing Fatigue a Sign of Imminent Heart Attack in Women: 515 women heart attack victims. 95% reported unusual symptoms during the weeks leading up to the heart attack: unusual fatigue (71 percent) and sleep disturbance (48 percent). Shortness of breath, indigestion and anxiety were also common. Less than a third reported chest discomfort, and when they did it was most often described as pressure, aching or tightness. Circulation 11/03

Congestive Heart Failure

G-alpha-i protein Involved: Beta-blockers can improve the symptoms of congestive heart failure. They reduce the levels of G-alpha-i and may forestall the natural decline of the aging heart. Duke, Oct. 4, 2003, J Cardiovascular Pharmacology. G-alpha-i mediates signaling through a family of G protein-coupled receptors (GPCR), which are important in cardiac function. Beta-adrenergic receptors (beta-AR), which respond to the hormones epinephrine and norepinephrine to increase cardiac output, are also members of this family. G-alpha-i is one protein that can prevent these hormones from "coupling" to beta-ARs, thereby decreasing the heart's contractability. The mechanism of action for G-alpha-i appears to be its ability to block adenylel cyclase, an enzyme that resides within cells and is responsible for transmitting messages within the cell in response to hormonal stimulation. Madan Kwatra.