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or ≥70% stenosis of other major coronary arteries by angiography.

Borderline lesions may be assessed with a pressure wire. Fractional flow reserve (FFR) of ≤0.8 demonstrates a hemodynamically significant lesion.

TREATMENT

GENERALMEASURES

BPcontrol goal: <140/90 mm Hg for most, except in elderly (2)[A]. Selected high-risk nondiabetic patients may benefit from a systolic blood pressure target of <120 mm Hg (3)[B].

Smoking cessation goal: complete cessation, no exposure to secondhand smoke or e-cigarettes

Physical activity goal: 30 to 60 minutes of moderate aerobic activity, at least 5 (preferably 7) days/week

Weight management goal: BMI 18.5 to 24.9 kg/m2; waist circumference <35 inches (women) or <40 inches (men)

Glycemic control in diabetics: Avoid hypoglycemic episodes.

MEDICATION

First Line

β-Blockers: decrease myocardial oxygen demand by lowering heart rate, BP, and contractility

–Improve mortality in patients with MI or heart failure and should be used as initial therapy (1)[A]

–Can improve symptoms of angina

–Metoprolol (25 to 400 mg daily [succinate] or divided BID [tartrate]) or carvedilol (3.125 to 25 mg BID). Adjust doses according to clinical response. Maintain resting heart rate 50 to 60 bpm.

–Side effects: bradycardia, fatigue, and sexual dysfunction

Calcium channel blockers (CCBs): cause arterial vasodilation, decreased myocardial oxygen demand, and improved coronary blood flow. Similar effectiveness to β-blockers; may be used instead of, or in addition to β- blockers (1)[A]. Only long-acting CCBs should be used:

–Dihydropyridine CCBs: Nifedipine (30 to 90 mg/day), amlodipine (5 to 10 mg/day), or felodipine (2.5 to 10 mg/day) work predominantly on arterial vasodilation and can improve coronary blood flow.

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–Nondihydropyridine CCBs: Diltiazem (120 to 480 mg/day) or verapamil

(120 to 480 mg/day) also have negative inotropic effects and should not be used in those with EF <40% as they may precipitate heart failure. Side

effects include constipation and peripheral edema.

Nitrates: dilate systemic veins and arteries (including coronary vessels) and cause decreased preload. At higher doses, they decrease BPand thus increase myocardial flow.

–Sublingual nitroglycerin (0.4 mg every 5 minutes for 2 to 3 doses) may be used for acute anginal episodes (1)[A].

–Long-acting nitrates such as isosorbide mononitrate (30 to 240 mg daily [extended release]) can be used for angina prophylaxis.

–Side effects include headache and hypotension but tend to improve with continued usage.

–Contraindicated with concomitant PDE5 inhibitor use

Lipid-lowering agents:

–High-intensity statin therapy is indicated for all patients with CAD regardless of lipid levels (4)[A].

–Statin therapy should also be encouraged for those with high CAD risk (lifetime risk ≥7.5–10%).

–Atorvastatin (20 to 80 mg/day) and rosuvastatin (10 to 40 mg/day) are highintensity statins.

–Statins reduce risk of MI and revascularization need. Side effects include myalgias, transaminitis, rhabdomyolysis (rare), and impaired glucose tolerance.

–Ezetimibe may be added to statin therapy, although evidence for improved clinical outcomes remains weak.

–Evolocumab and possibly other PCSK-9 inhibitors can further reduce LDL levels when used in combination with statins for high-risk patients and may reduce cardiovascular events (3) but are very expensive. Clinical trials are

ongoing.

Antiplatelets: decrease risk of thrombosis

–Aspirin (75 to 162 mg/day) decreases risk of first MI and reduces adverse cardiovascular events in those with stable angina (1)[A].

–Clopidogrel (75 mg/day) may be used in patients with contraindications to aspirin (1)[A].

–Dual antiplatelet therapy with aspirin + clopidogrel, prasugrel, or ticagrelor is indicated after MI or percutaneous coronary intervention (PCI) (use

prasugrel only after PCI).

Angiotensin-converting enzyme inhibitors (ACEIs): act on the renin-

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FOLLOW-UPRECOMMENDATIONS

Lifestyle modifications should be aggressively stressed at every visit.

Patients should be followed clinically; routine stress testing is not necessary for asymptomatic patients.

Patient Monitoring

Frequent follow-up after initial event: every 4 to 6 months in first year and then 1 to 2 times per year

DIET

Reduced intake of trans-fatty acids (1)[C]

Adherence to dietary modification for comorbid conditions (diabetes, heart failure, hypertension)

PROGNOSIS

Variable; depends on severity of symptoms, extent of CAD, and left ventricular function.

COMPLICATIONS

ACS, arrhythmia, cardiac arrest, heart failure

REFERENCES

1.Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60(24):e44–e164.

2.James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA.

2014;311(5):507–520.

3.Sabatine MS, Guigliano R, Keech AC, et al; for FOURIER Steering Committee and Investigators. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017;376(18):1713–1722.

4.Stone NJ, Robinson JG, Lichtenstein AH, et al; for American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHAguideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 2014;129(25 Suppl

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2):S1–S45.

SEE ALSO

Algorithm: Chest Pain/Acute Coronary Syndrome

CODES

ICD10

I25.119 Athscl heart disease of native cor art w unsp ang pctrs

I25.118 Athscl heart disease of native cor art w oth ang pctrs I20.9 Angina pectoris, unspecified

CLINICALPEARLS

Maximize antianginal therapy: Combine β-blockers, CCBs, and nitrates as tolerated, along with high-intensity statin therapy.

Lifestyle changes and optimal medical therapy must be emphasized to prevent progression of atherosclerosis and to control contributing risk factors.

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COSTOCHONDRITIS

Smriti Ohri, MD Scott A. Fields, MD, MHA

BASICS

DESCRIPTION

Anterior chest wall pain and tenderness of the costochondral and costosternal regions

System(s) affected: musculoskeletal

Synonym(s): costosternal syndrome; parasternal chondrodynia; anterior chest wall syndrome (1)

EPIDEMIOLOGY

Predominant age: 20 to 40 years

Predominant gender: female

Incidence

30% emergency room visits for chest pain

20% of chest pain visits in primary care are for musculoskeletal causes (13% for costochondritis).

ETIOLOGYAND PATHOPHYSIOLOGY

Not fully understood

RISK FACTORS

Unusual physical activity or overuse stressing the upper extremity

Recent trauma (including motor vehicle accident, domestic violence) or newonset physical activity

Recent upper respiratory infection (URI) with coughing

DIAGNOSIS

Pain is usually sharp, achy, or pressure-like, involving multiple (and mostly unilateral 2nd to 5th) costal cartilages.

Exacerbated by upper body movements and exertional activities

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Reproduced by palpation of the affected cartilage segments

Chest tightness is often associated with the pain.

HISTORY

Acomplete and thorough history is mandatory for the diagnosis, with special emphasis on cardiac risk factor evaluation.

Social history: careful screening and evaluation for domestic violence and substance abuse

PHYSICALEXAM

Focus on excluding other serious conditions that may present with chest pain.

Tenderness over the costochondral junctions is necessary to establish the diagnosis but does not completely exclude other causes of chest pain.

If swelling or redness of costal cartilage is present, the presentation is often termed Tietze syndrome.

Movement of upper extremity of the same side may reproduce the pain (1).

Epigastric (gastroesophageal reflux disease) and right upper quadrant (gallbladder disease) palpation

Pediatric Considerations

Consider psychogenic chest pain in children who perceive family discord.

Consider slipping rib syndrome in children with chronic chest and abdominal pain (2).

Geriatric Considerations

Multiple problems cause chest pain, emphasizing the importance of a thorough history and physical exam.

Consider herpes zoster in elderly patients.

DIFFERENTIALDIAGNOSIS

Cardiac

–Coronary artery disease (CAD)

–Cardiac contusion from trauma

–Aortic aneurysm

–Pericarditis

–Myocarditis

Gastrointestinal

– Gastroesophageal reflux

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–Peptic esophagitis

–Esophageal spasm

–Cholecystitis

Musculoskeletal (2)

–Fibromyalgia

–Slipping rib syndrome

–Costovertebral arthritis

–Painful xiphoid syndrome

–Rib trauma

–Ankylosing spondylitis

–Precordial catch syndrome

Psychogenic

–Anxiety disorder

–Panic attacks

–Hyperventilation

Respiratory

–Asthma

–Pulmonary embolism

–Pneumonia

–Chronic cough

–Pneumothorax

Other

–Domestic violence and abuse

–Herpes zoster

–Spinal tumor

–Metastatic cancer

–Substance abuse (cocaine)

DIAGNOSTIC TESTS & INTERPRETATION

Primarily a clinical diagnosis

Use laboratory exams and imaging to exclude other diagnoses.

ESR is inconsistently elevated.

Initial Tests (lab, imaging)

No imaging is indicated for the diagnosis of costochondritis; chest x-ray and rib films are often normal.

Diagnostic Procedures/Other

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None indicated for the diagnosis of costochondritis

Consider ECG in patients age >35 years and for patients with history or risk of CAD.

Consider chest x-ray in patients with cardiopulmonary symptoms.

Consider spiral CT for pulmonary embolism and D-dimer if history or risk factors are present.

Test Interpretation

Costochondral joint inflammation

TREATMENT

Reassurance of benign nature of condition and potential for long, slow recovery from pain

GENERALMEASURES

Rest, and heat (or ice) massage

Stretching exercises

Minimize symptom-provoking activities (e.g., reduce frequency or intensity of exercise/work activity).

MEDICATION

Pain relief with NSAIDs (ibuprofen, naproxen, or diclofenac), acetaminophen or other analgesics

Use of skeletal muscle relaxants may be beneficial if associated with muscle spasm.

ISSUES FOR REFERRAL

Consider referral to physical therapy for pain reduction and improvement in function (3)[B].

Refractory cases of costochondritis can be treated with local injections of combined lidocaine/corticosteroid into costochondral areas; rarely necessary (4)[C]

COMPLEMENTARY& ALTERNATIVE MEDICINE

Limited data on use of manipulation or ice massage but may be safely tried if

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patient interested

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Only if differential diagnosis is unclear and cardiac or other serious etiology of chest pain is being considered

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Follow-up within 1 week if diagnosis is unclear or symptoms do not abate with conservative treatment

PATIENT EDUCATION

Educate regarding the self-limited (although potentially recurrent) nature of the illness.

Instruct patient on proper physical activity regimens to avoid overuse syndromes.

Avoid sudden, significant changes in activity.

PROGNOSIS

Self-limited illness lasts for weeks to months and usually abates by 1 year: sometimes chronic particularly in adolescents

Often recurs

COMPLICATIONS

Incomplete attention to differential diagnosis or overly aggressive interventions to ensure a more life-threatening diagnosis is not missed.

REFERENCES

1.Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617–620.

2.Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863–887.

3.Zaruba RA, Wilson E. Impairment based examination and treatment of costochondritis: a case series. Int J Sports Phys Ther. 2017;12(3):458–467.

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