1. Chest pain: pivotal questions for diagnosis: 
- acuity of onset
- pleuritic vs non-pleuritic
2. Differential: 
- Skin: zoster
- Breast: fibroadenoma, gynecomastia
- MSK: costochondritis, precordial catch syndrome, pec muscle strain, rib fracture, spine spondylosis (C4 to T6), myositis
- Esophagus: spasm, GERD, tear/rupture, cancer, medication-esophagitis (K-dur, tetracycline, bisphosphonates)
- GI: peptic ulcers, liver abscess (any abscess under diaphragm), pancreatitis, GB disease,
- Lung: PE, pneumonia (viral/bacterial infection of parenchyma or pleura), cancer (of pleura or parenchyma), pHTN, serositis of pleura
- Cardiac: MI, pericarditis, myocarditis
- Mediastinum: lymphoma, thymoma
- Aorta: AAA, dissection
- Psych
3. Stable angina with normal coronaries
- LVH
- Bad anemia
- Aortic stenosis (more O2 demand, increased diastolic filling pressure that compresses coronaries and compromises perfusion) (source)
- Tachycardia
- Heart failure (filling pressures)
4. Atypical presentations of stable angina
- Atypical triggers: cold weather, emotional stress, large meals
- Atypical symptoms: dyspnea, nausea/indigestion, pain elsewhere (jaw, neck, teeth, back, abdomen), palpitations, syncope, weakness/fatigue
- In women, they tend to describe the pain as more "burning" or "tender"
5. Risk factors for CAD
- Age > 55 (men), >65 (women)
- Chronic diseases (HTN, DM, etc), smoking, fam hx of CAD at <55 men and <65 women
- Bad lipids
- Hyperhomocysteinemia (causes endothelial damage)
- Elevated CRP
- Plasma fibrinogen
- Microalbuminemia
6. Likelihood of CAD
- Sx: substernal location, precipitated by exercise, relieved by rest
-0/3 sx = asymptomatic, 1/3 sx = nonanginal, 2/3 atypical angina, 3/3 typical angina

Overall prevalence of CAD at autopsy = asymptomatic 

7. Initial workup

- Lipids/A1c/glucose: tells you about risk factor diseases

- Hemoglobin/TSH: tells you alternate causes of angina 

- Resting EKG: look for current/past ischemia/infarction

- Cardiac enzymes

8. Stress test

- Purpose: diagnose CAD, determine whether they should get meds only, stent or CABG

- How it works: induce ischemia (exercise, dobutamine, adenosine, dipyridamole), detect ischemia (EKG, echo, nuclear imaging) 

- When not to get it: when you're so sure that they have CAD that you can go straight to cath, or they aren't a candidate for stent or CABG anyways 

9. When to get the more expensive imaging stress tests 

- Abnormal resting EKG

- High risk patients (where you need a high NPV to definitively rule it out) 

- Previous stent/cabg

10. When to go to the cath lab

- Stress test showing severe ischemia or ischemia at low stress

- Stress test with uncertain diagnosis

- Disabling symptoms despite treatment

- Clinical heart failure