Personal Details:
Mr. Ramesh Kumar, 58-year-old male, retired school teacher

Presenting Complaint:

• Chest pain for 2 months

History of Presenting Illness:
Mr. Ramesh reports episodes of central chest pain for the past 2 months. The pain is described as a heavy, squeezing sensation located behind the sternum, sometimes radiating to his left shoulder and jaw. Each episode lasts about 5–10 minutes and typically occurs when he walks briskly or climbs stairs. The pain is relieved by rest and occasionally by taking a tablet of nitroglycerin under his tongue.

He denies any pain at rest, but notes that the frequency of episodes has increased over the past two weeks. He sometimes feels short of breath and sweaty during the pain, but there is no associated palpitations, syncope, or nausea. There is no history of fever, cough, or abdominal pain.

Past Medical History:

• Hypertension for 8 years, on regular medication

• Type 2 diabetes mellitus for 5 years, on oral hypoglycemics

• No previous history of heart attack or stroke

• No prior hospitalizations for similar complaints

Personal History:

• Diet: High in carbohydrates and fats

• Appetite: Normal

• Bowel and bladder habits: Normal

• Sleep: Normal

• Addictions: Non-smoker, does not consume alcohol

• Physical activity: Sedentary lifestyle since retirement

Family History:

• Father died of myocardial infarction at age 62

• Mother has hypertension

Socioeconomic History:

• Retired school teacher, living with spouse

• Middle-class socioeconomic status

• Access to regular healthcare

• No financial constraints for medical treatment

Drug History:

• Amlodipine 5 mg once daily

• Metformin 500 mg twice daily

• Atorvastatin 20 mg once daily

• No known drug allergies

Systemic Enquiry:

• No cough, hemoptysis, fever, abdominal pain, or leg swelling

Case Summary

Mr. Ramesh Kumar, a 58-year-old male with hypertension and diabetes, presents with a 2-month history of exertional, central, squeezing chest pain radiating to the left shoulder and jaw, relieved by rest and nitroglycerin, with increasing frequency over the past two weeks. He has a strong family history of coronary artery disease and multiple cardiovascular risk factors.

Differential Diagnosis

1. Stable Angina Pectoris

   • Most likely, given exertional, relieved-by-rest chest pain with classic features and risk factors.

2. Unstable Angina

   • Possible, considering the recent increase in frequency and severity of pain.

3. Gastroesophageal Reflux Disease (GERD)

   • Can cause retrosternal pain, but usually related to meals and not relieved by rest or nitroglycerin.

4. Musculoskeletal Chest Pain (Costochondritis)

   • Pain is usually localized, may be reproduced by palpation, and not typically exertional or relieved by nitroglycerin.

5. Atypical/Non-cardiac Chest Pain

   • Includes anxiety or panic attacks, but lacks typical exertional pattern.

6. Other Cardiac Causes (e.g., Aortic Stenosis, Hypertrophic Cardiomyopathy)

   • May present with exertional chest pain, but less likely without other suggestive symptoms or findings.

Viva Questions and Answers on Chest Pain (Angina)

1. What is angina pectoris?
Angina pectoris is chest pain or discomfort resulting from transient myocardial ischemia, typically due to a mismatch between myocardial oxygen supply and demand, most often caused by coronary artery disease.

2. What are the typical features of anginal chest pain?
Anginal pain is usually retrosternal, described as tightness, heaviness, or squeezing. It may radiate to the left arm, neck, jaw, or back, is precipitated by exertion or emotional stress, and relieved by rest or nitroglycerin within minutes.

3. What are the risk factors for coronary artery disease?
Major risk factors include hypertension, diabetes mellitus, dyslipidemia, smoking, family history of premature CAD, obesity, sedentary lifestyle, and advancing age.

4. How do you differentiate angina from non-cardiac chest pain?
Angina is exertional, relieved by rest or nitroglycerin, and often radiates to typical sites. Non-cardiac pain (e.g., GERD, musculoskeletal) is usually related to meals or movement, may be localized, and is not relieved by rest or nitroglycerin.

5. What is the difference between stable and unstable angina?
Stable angina occurs with predictable exertion or stress and is relieved by rest. Unstable angina occurs at rest, is new in onset, or has increasing frequency or severity, and indicates a higher risk of myocardial infarction.

6. What is the role of nitroglycerin in angina?
Nitroglycerin is a vasodilator that reduces preload and myocardial oxygen demand, providing rapid relief of anginal pain.

7. What investigations are indicated in a patient with suspected angina?

• ECG (resting and stress)

• Cardiac biomarkers (to rule out MI)

• Echocardiography

• Exercise stress test

• Coronary angiography (if indicated)

• Lipid profile, blood glucose, renal function tests

8. What is the initial management of stable angina?
Lifestyle modification, anti-anginal medications (nitrates, beta-blockers, calcium channel blockers), antiplatelet agents (aspirin), statins, and control of risk factors like hypertension and diabetes.

9. When should a patient with angina be referred for coronary angiography?
If there is high-risk or refractory angina, positive stress test, or suspicion of acute coronary syndrome, coronary angiography is indicated to assess the severity and plan for revascularization.

10. What complications can arise from untreated or progressive angina?
Progression to unstable angina, myocardial infarction, arrhythmias, heart failure, and sudden cardiac death.