Prodromal Angina

Worsening chest pain, increasing in severity and becoming more prolonged and unbearable as acute myocardial infarction is imminent.

No problem in identifying these patients.
Symptoms stop them "dead in their tracks".

Recognizable: Delay is caused by denial.

Chest pressure is often the initial complaint, but includes chest discomfort, burning ache, full feeling that is centrally located, coming and going (stuttering), increased with activity and relieved with rest.

"Not pain, Doc! As if it has to be painful either severe or prolonged to justify the ED visit. First Clue to the missing piece of the puzzle.

Poorly recognizable: Delay in most cases is caused not by denial,
but lack of awareness that these symptoms are important.

The public is unaware in most cases that soft symptoms are important enough to check out.

Characteristics of this stage:
- Symptoms usually are put on the back burner and business as usual is conducted. (Cerebral bypass)
- Call 911? "You've got to be kidding!"
- ED? "Ridiculous for me to go!"
- Bystanders do not recognize these symptoms in patients. Thus there is no formula like CPR is for cardiac arrest victims.

Recommendations:

THE IMPORTANCE OF THE LEARNING CURVE

Seemingly we have all the ingredients for providing early cardiac care (ECC) but we desperately need a plan for setting up early cardiac care centers and for taking advantage of the fact that heart attacks have beginnings. Just as CPR got CCUs started in hospitals, so too can thrombolytic therapy (tPA) be the building block for the community part of this equation. Early Cardiac Care cannot occur unless we get started on that learning curve and allow "progress to beget progress". The first major step is creating an awareness program for chest pain symptomatology and the delay in seeking early care. Once started, we could quickly increase our knowledge of how to educate and how to change victim behavior and so take advantage of what we know. All too often victims are too preoccupied with what they are doing and don't take the time to check out the early signs. Creating an awareness in both patients and the public can go a long way in linking up persons in need with early cardiac care.

ANNALS OF INTERNAL MEDICINE 1941 14:1155

PREMONITORY SYMPTOMS OF ACUTE CORONARY OCCLUSION;
A STUDY OF 260 CASES

Summary and Conclusions

1. Premonitory symptoms were present in 44.2 percent of 260 patients with acute coronary occlusion from whom detailed histories could be elicited.
2. In most cases the premonitory symptoms consisted of substernal or precordial pain or discomfort. Other prodromes were fatigue, weakness, gastric distress,
-dyspnea, palpitations, nervousness, and dizziness.
3. The sudden appearance of a typical angina syndrome or the sudden acceleration of a previously existing anginal syndrome frequently preceded the attack of occlusion.
4. The premonitory symptoms usually appeared within 24 hours prior to the acute attack, but in some cases they began two or three weeks before.
5. The duration of symptoms varied from a few minutes to several hours. Although the premonitory pain was usually intermittent or continuous, a pain-free period frequently intervened before the onset of acute occlusion.
6. The onset of premonitory symptoms occurred during rest in 28.5 per cent of the cases, during mild or moderate activity or walking in 68.5 percent, and during strenuous effort in 2.9 per cent.
7. The premonitory symptoms were not associated with clinical evidence of myocardial infarction. Fever, leukocytosis, tachycardia, drop in blood pressure, and characteristic electrocardiographic changes were absent. These factors are significant in differential diagnosis.
8. The anatomic basis for the premonitory symptoms is assumed to be a gradual occlusion of the lumen of the coronary artery by progressive or recurrent intramural hemorrhage or by primary thrombosis on a plaque, which many take hours or days for completion. The initiation and progression of coronary occlusion occurs irrespective of physical activity or lack of activity. However, the physiological coronary insufficiency and myocardial ischemia which ensue may result in precordial pain, which is often brought on or intensified by effort.
9. Early recognition of the premonitory symptoms should lead to a reduction of heart failure and decrease the mortality rate by means of immediate bed rest, which, however, will probably not prevent the impending occlusion.

REFERENCES
1. Wearn, JT: Thrombosis of the coronary arteries with infarction of the heart. Am Jr. Med Sci., 1923, clxv, 250.
2. Karns, MH: Prodromal symptoms in angina pectoris. Am Jr. Med. Sci., 1926, clxxii,
418.

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