Chest Pain OSCE - Stable Angina

Diagnosis: Stable Angina

Case Overview

  • Age/Sex: 71-year-old female
  • Occupation: Retired primary school teacher
  • Setting: Primary care clinic (walk-in appointment)
  • Chief complaint: "Chest pain"

Patient Script

Who I Am

I am 71, retired, live with my husband, and I've had type 2 diabetes for many years.

What Brings Me In

I've been getting chest pain when I walk and it seems to be happening more often lately.

My Story

About three months ago I first noticed a tight feeling in the middle of my chest when I hurried or climbed stairs. At first it happened maybe once or twice a month, but for the last two weeks it's happening almost every day when I walk briskly to the shops or go up a flight of stairs. The pain is a central squeezing/pressure that sometimes goes into my left arm and my jaw. It usually lasts about 5–10 minutes and then gets better if I sit down and rest — or if I use my little spray under my tongue it helps in a couple of minutes. I also get a bit short of breath with it and feel a bit sweaty. It never stays all day and I haven't had a sudden crushing pain that didn't go away with rest.

I've had a bit of indigestion after spicy food recently and I get an achy pain in my left shoulder when I reach over to put things on a high shelf (that started after I carried a heavy box last month). I also had a chesty cough a few weeks ago but that has mostly cleared up.

My Medical Background

  • Past medical history: Type 2 diabetes (diagnosed 15 years ago), hypertension, hyperlipidaemia, chronic kidney disease stage 3 (mild)
  • Medications: Metformin 500 mg twice daily, gliclazide 80 mg daily, lisinopril 10 mg daily, atorvastatin 20 mg nightly, aspirin 75 mg daily, omeprazole occasionally for heartburn
  • Allergies: Penicillin — rash years ago
  • Social: Ex-smoker (20 pack-years, quit 15 years ago), drinks 1–2 units of wine a week, lives with husband, walks the dog most days
  • Family: Father had a heart attack at 68

What I Think & Worry About

  • I think it might be something to do with my heart because it gets worse with walking.
  • I worry it could be a heart attack or something serious that will stop me being independent.
  • I hope you can tell me if it's dangerous and what I should do to make it better.

If You Ask Me About Other Symptoms...

  • Chest pain character: "A tight, squeezing pressure in the middle of my chest, not sharp."
  • Timing: "Usually starts while walking uphill or climbing stairs, lasts 5 to 10 minutes, gets better with rest or my spray."
  • Associated: "I get short of breath and a bit sweaty sometimes; I haven't fainted."
  • Response to meds: "Sublingual GTN spray helps in a couple of minutes."
  • Recent infection: "I had a cough about 3–4 weeks ago but it’s nearly gone now."
  • Gastro symptoms: "Occasionally heartburn after spicy food, but that’s not every time."
  • Palpitations: "Sometimes my heart feels like it flutters after a strong coffee, but it stops quickly."
  • Leg symptoms: "No swelling in my legs and no calf pain when walking."

Clinical Summary

Examination

  • General: Alert, comfortable at rest
  • Vitals: BP 148/88 mmHg (sitting), HR 76 bpm regular, RR 16/min, SpO2 96% on room air, afebrile
  • BMI: 31 kg/m2
  • CVS: Heart sounds normal S1/S2, soft fourth heart sound (S4) present; no murmurs audible at rest
  • JVP: Not elevated
  • Respiratory: Chest clear, no crepitations
  • Abdomen: Soft, non-tender
  • Peripheral: Pulses present and equal, no peripheral oedema
  • Capillary glucose (fingerstick): 10.2 mmol/L

Investigations

  • ECG: Sinus rhythm 78 bpm; lateral T-wave inversions in V5–V6 (nonspecific, could represent ischaemia or old changes)
  • Troponin I: <0.01 ng/mL (normal <0.04 ng/mL) (not suggestive of acute MI)
  • Chest X-ray: Heart size normal, lungs clear (no consolidation)
  • HbA1c: 7.8% (62 mmol/mol) (suboptimally controlled diabetes)
  • Lipids: Total cholesterol 5.8 mmol/L, LDL 3.2 mmol/L, HDL 1.0 mmol/L, triglycerides 1.9 mmol/L
  • Creatinine: 120 µmol/L (eGFR ~45 mL/min/1.73m2) (chronic kidney disease stage 3)
  • FBC: Hb 12.8 g/dL, WCC normal, platelets normal
  • Consider for further testing: Exercise stress test / myocardial perfusion imaging or CT coronary angiography (depending on local availability and pre-test probability)

Diagnosis

  • Primary diagnosis: Stable angina (typical exertional central chest tightness radiating to left arm/jaw, lasting 5–10 minutes, reproducible with exertion and relieved by rest and sublingual GTN; multiple atherosclerotic risk factors including long-standing diabetes, hypertension, hyperlipidaemia, age)

  • Differential diagnoses:

    • Gastro-oesophageal reflux disease: possible given intermittent heartburn and response to antacid/omeprazole, but pain is exercise-related and relieved by rest rather than antacids.
    • Musculoskeletal chest wall pain: left shoulder pain after lifting is a red herring; reproducible shoulder pain on movement suggests local musculoskeletal component but does not explain exertional central chest pressure with radiation.
    • Panic/anxiety: palpitations after coffee and anxiety may contribute, but the predictable exertional pattern and relief with GTN point toward ischaemia.
    • Pulmonary causes (PE, pneumonia): less likely given normal oxygenation, clear chest x-ray and absence of pleuritic pain or haemoptysis.

Management

  • Immediate/short-term:

    • Advise that symptoms consistent with stable angina; ensure patient understands symptoms requiring urgent review (pain lasting >20 minutes, not relieved by GTN, syncope, severe breathlessness).
    • Continue aspirin 75 mg daily and atorvastatin; consider increasing atorvastatin to high-intensity therapy (e.g., atorvastatin 40 mg nightly) after review of tolerability and CKD.
    • Start or optimize beta-blocker for symptom control and secondary prevention (e.g., metoprolol tartrate 25 mg twice daily, titrate as tolerated) unless contraindicated.
    • Provide sublingual GTN education (use at onset of typical pain; if no relief after one dose and pain persists >5 minutes, call ambulance / attend ED).
    • Optimize blood pressure and glycaemic control (review lisinopril and oral diabetic meds; arrange diabetes review for HbA1c target discussion).

  • Investigations/referral:

    • Arrange non-invasive ischaemia testing (exercise ECG or functional imaging such as stress myocardial perfusion imaging) to assess severity and ischemic burden.
    • If non-invasive test is positive or symptoms are limiting despite medical therapy, refer to cardiology for consideration of coronary angiography and revascularisation.
    • Baseline blood tests for treatment monitoring (liver function, CK if changing statin dose, renal function monitoring given CKD).

  • Lifestyle and education:

    • Smoking cessation reinforcement (ex-smoker), weight reduction, regular moderate exercise as tolerated, low-sodium/low-fat diet, and diabetic dietary advice.
    • Vaccinations as appropriate (influenza, pneumococcal) given age and comorbidities.

Key Learning Points

  • Typical exertional chest pain relieved by rest or sublingual nitrates, especially in a patient with multiple cardiovascular risk factors (notably diabetes), is highly suggestive of stable angina.

  • Initial assessment should exclude acute coronary syndrome (history, ECG, troponin) and then focus on risk stratification, symptom control (anti-anginal therapy and secondary prevention) and appropriate non-invasive testing or cardiology referral for further evaluation.

  • Beware red herrings (concurrent dyspepsia, recent cough, localized shoulder pain, caffeine-related palpitations); correlate symptoms with reproducible exertional pattern and response to GTN to support cardiac aetiology.

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