What is the appropriate management plan for a 65-year-old male presenting with angina?

SOAP Note for a 65-Year-Old Male Presenting with Angina

Subjective

• 65-year-old male presenting with substernal chest discomfort described as pressure-like, exacerbated by physical exertion and relieved by rest 1
• Discomfort typically lasts several minutes and is relieved when activity stops 1
• No radiation to jaw, neck, arm, or shoulder reported
• No associated symptoms of nausea, vomiting, diaphoresis, or unexplained fatigue
• No prior history of coronary artery disease or myocardial infarction
• No prior cardiac interventions

Objective

• Vital Signs: BP 138/84, HR 76, RR 16, Temp 98.6°F, O2 sat 98% on room air
• General: Alert, oriented, in no acute distress
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
• Respiratory: Clear to auscultation bilaterally
• ECG: Normal sinus rhythm, no ST-segment changes or T-wave inversions
• Laboratory: Troponin negative, lipid panel pending

Assessment

• Stable angina pectoris, likely due to coronary artery disease 1
• Risk factors include male gender and age >55 years 1
• Differential diagnosis includes:
  • Unstable angina/NSTEMI (ruled out by negative troponin and absence of rest pain) 1
  • Vasospastic angina (less likely given exertional pattern) 1
  • Non-cardiac chest pain (less likely given classic exertional pattern) 1

Plan

The recommended management includes immediate initiation of sublingual nitroglycerin for acute relief, daily aspirin 75-300mg, and a beta-blocker (such as metoprolol) as first-line anti-anginal therapy, with lifestyle modifications including smoking cessation, Mediterranean diet, and moderate physical activity. 1

Immediate Management:

• Sublingual nitroglycerin 0.4mg as needed for acute angina episodes 1
• Instruct patient to sit when taking first dose to avoid hypotension 1
• Advise to seek medical attention if pain persists >10-20 minutes after rest and nitroglycerin 1

Pharmacologic Therapy:

• Aspirin 81mg daily for antiplatelet effect 1
• Metoprolol 25mg twice daily (first-line anti-anginal therapy) 1, 2
  • Caution: Monitor for bradycardia and avoid abrupt discontinuation 2
• Consider adding long-acting nitrate if symptoms persist 1
• For patients with continued symptoms, calcium channel blockers or ranolazine may be added 1, 3

Risk Factor Modification:

• Smoking cessation strongly encouraged 1
• Mediterranean diet with emphasis on vegetables, fruits, fish, and poultry 1
• Weight reduction if BMI elevated 1
• Moderate physical activity within patient's limitations 1
• Blood pressure target: 120-130 mmHg systolic 1
• Lipid management: Statin therapy based on lipid panel results 1

Diagnostic Workup:

• Exercise stress test to confirm diagnosis and assess functional capacity 1
• Consider coronary angiography or coronary CTA to determine extent of coronary disease 1
• Echocardiogram to assess left ventricular function 1

Follow-up:

• Return visit in 2 weeks to assess symptom control 1
• Medication adjustment based on symptom response
• Discuss potential need for revascularization if symptoms remain refractory to medical therapy 1

Patient Education:

• Explain nature of angina and its relationship to coronary artery disease 1
• Instruct on proper use of sublingual nitroglycerin (before activities that might trigger angina) 1, 4
• Warn about potential side effects of medications (headache with nitrates, fatigue with beta-blockers) 1
• Emphasize importance of calling emergency services if chest pain persists >20 minutes or is unrelieved by rest and nitroglycerin 1