A 67 year old male presents to the GP with intermittent chest pain. He describes a crushing chest pain that comes on while he is gardening that goes away when he sits down for 4 minutes. He has also noticed jaw pain, breathlessness and sweating that comes on at the same time and also completely resolves with rest.

What is the most likely diagnosis?

Options:
explanation: COPD can present with exertional breathlessness and is a good differential to consider in anyone presenting with exertional breathlessness and a significant smoking history. However, this would not explain the associated chest pain, which is more in keeping with angina. This patient's smoking history is also not specified in this question
name: Chronic obstructive pulmonary disease
label: d
answer: no
explanation: This is a classical description of stable angina pectoris. This patient is present with all 3 diagnostic criteria for stable angina: constricting chest/jaw/arm pain, exercise as a trigger for the pain and rest for 5 minutes/glyceryl trinitrate resolving the pain. This is a typical history of angina and the next steps would involve basic investigations (bloods including full blood count and thyroid function tests), confirmation of the diagnosis (usual first line investigations is a CT coronary angiography) via referral to cardiology and initiation of treatment. Treatment includes symptomatic treatment (usually with glyceryl trinitrate), prophylaxis of attacks (usually with a cardioselective beta blocker or a calcium channel blockers) and drugs for secondary prevention of cardiovascular disease (e.g. statin, aspirin)
name: Stable angina
label: a
answer: yes
explanation: Although panic disorder can present with chest pain, breathlessness and sweating, this chest pain is more cardiac in nature (crushing with radiation to jaw). This patient also doesn't mention any features of worrying or panicking and his symptoms have a clear association with exercise which would be not be likely to trigger an anxiety attack by itself
name: Panic disorder
label: e
answer: no
explanation: Acute coronary syndrome will also present with a similar chest pain as both conditions are associated with myocardial ischaemia. However, in stable angina this is related to coronary artery atherosclerosis making it more difficult to meet the demand of the myocardium during exercise, whereas many causes of acute coronary syndrome are related to thrombi in the coronary arteries. As a result, the main differentiating clinical feature is that stable angina will resolve within 5 minutes, whereas acute coronary syndrome will last longer. Stable angina is a risk factor for acute coronary syndrome and it is important to give patients specific advice around this (if getting anginal chest pain: rest and use 2 GTN sprays, wait 5 minutes, use 2 GTN sprays, wait 5 minutes, if symptoms are still there they must ring an ambulance)
name: Acute coronary syndrome
label: b
answer: no
explanation: Ludwig's angina, also known as cellulitis of the floor of the mouth, is an oral infection causing swelling of the mouth which can lead to airway compromise. It is usually associated with a dental abscess. Although this would present with pain around the jaw, this would not explain the chest pain. The root of the word "angina" means "strangling", which is why the word is used to describe two seemingly unrelated conditions
name: Ludwig's angina
label: c
answer: no

Correct answer: a