Stable angina

stable-angina

Angina pectoris means: I cry

Angina pectoris – commonly known as angina – is chest pain  due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries. The main cause of Angina pectoris is coronary artery disease, due to atherosclerosis  of the arteries feeding the heart. The term derives from the Latinangina (“infection of the throat”) from the Greek ἀγχόνη ankhonē (“strangling”), and the Latin pectus (“chest”), and can therefore be translated as “a strangling feeling in the chest”.

There is a weak relationship between severity of pain  and degree of oxygen deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a Myocardial infraction(commonly known as a heart attack), and a heart attack can occur without pain). In some cases angina can be extremely serious and has been known to cause death. People that suffer from average to severe cases of angina have an increased percentage of death before the age of 55, usually around 60%.

Angina pectoris is the symptom complex caused by transient myocardial ischemia and constitutes clinical syndrome rather than a disease; it may occure whenever there is an imbalance between myocardial oxygen supply and demand.

Angina is a clinical syndrome characterized by paroxysmal chest pain due to transient myocardial ischemia.

Types of angina: There are several types of angina:

  1. Stable/Classical/typical/exertional angina.
  2. Unstable/Crescendo/Pre-infraction angina.
  3. Prinzmetal’s or varinal angina.
  4. Decubitus angina.
  5. Nocturnal angina.

Activities precipitating angina:

[A]Common:

  1. Physical exertion.
  2. Cold exposure.
  3. Heavy meals.
  4. Intense emotion.

[B]Uncommon:

  1. Lying flat (decubitus angina)
  2. Vivid dreams (nocturnal angina).

Causes:

Major risk factors:

  • Age (≥ 55 years for men, ≥ 65 for women)
  • Cigarette smoking
  • DM
  • Dyslipidemia
  • Family history of premature cardiovascular disease  (men <55 years, female <65 years old)
  • Hypertension  (HTN)
  • Kidney disease (Microalbuminuria  or GFR <60 mL/min)
  • Obesity (BMI  ≥ 30 kg/m2)
  • Physical inactivity
  • Prolonged psychosocial stress.

Routine counseling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behavior, and thus is not recommended.

Conditions that exacerbate or provoke angina

  • Medications
  •  Vasodilators
  • Excessive thyroid replacement
  • Vasoconstrictors
  • Polycythemia which thickens the blood causing it to slow its flow through the heart muscle
  • hypothermia
  • Hypovolaemia
  • Hypervolaemia

Other medical problems

  • profound anemia
  • uncontrolled HTN
  • hyperthyroidism
  • hypoxemia

Other cardiac problems

  • tachyarrhythmia
  • bradyarrhythmia
  • valvular heart disease
  • hypertrophic cardiomyopathy

Pathophysiology: Angina results when there is an imbalance between the heart’s oxygen demand and supply. This imbalance can result from an increase in demand (e.g. during exercise) without a proportional increase in supply (e.g. due to obstruction or atherosclerosis of the coronary arteries).However, the pathophysiology of angina in females varies significantly as compared to males. Non-obstructive coronary disease is more common in females.

Clinical features: Patient usually middle aged present with:

Characteristic of angina pain:

  1. Site: Retrosternal pain (mainly), left side of chest (may be).
  2. Character: Oppression or tightness in the chest- like a band round the chest, dull or choking etc.
  3. Radiation: left shoulder and ulnar border of left hand, sometimes to neck, jaw, and back and occasionally to the epigastric or interscapular region.
  4. Duration: Few second too few minutes, usually 2-5 min.
  5. Aggravated by: Exercise, emotion, after meal, in the cold, walking uphill or into a strong wind.
  6. Relieved by: Taking rest or GTN ( glyceryl trinitrate)

Physical examination: is frequently negative but should include a careful search for evidence of-

  1. Important risk factors. e.g.
  • Smoking- Nicotine stains.
  • Hypertension-High BP, loud.
  • Diabetes, myxoedema.
  • Hyperlipidaemia-tendon xanthomas, archus lipids.
  1. Contributory factors: e.g.
  • Obesity, anaemia.
  • Thyrotoxicosis.
  • Aortic valve disease.
  1. Left ventricular dysfunction: e.g.
  • Gallop rhythm.
  • Cardiomegaly.
  • Basal crackles.
  • Electied blood pressure.
  1. Generalised arterial disease: e.g.
  • Carotid bruits.
  • Peripheral vascular disease.

Differential diagnosis:

  1. Musculoskeletal pain.
  2. Pericardial pain and
  3. Oesophageal pain.

Investigations:

  1. Resting ECG: Normal in most patients. May show evidence of previous MI.
  2. ETT: Reversible S-T segment depression or elevation with or without T inversion.
  3. Isotope scanning with Thallium 201, using Gamma camera showing cold spot.
  4. Coronary angiography: Provides detail information about the site, extent and nature of coronary artery disease.
  5. Others:
  • X-ray chest: Normal.
  • Urine for sugar if Diabetes.
  • Serum cholesterol, serum triglyceride & lipoprotein.

Management of angina pectoris: (AP)

The management of angina pectoris involves:

  • A careful assessment of the like extent and severity of arterial disease.
  • The identification and control of significant risk factors (e.g. smoking, hypertension, hyperlipidaemia)
  • The use of measures to control symptoms.
  • The identification of high risk patients and application of treatment to improve life expectancy.

Drug therapy:

[A]Antiplatelet therapy: Aspirin, Clopidogrel.

[B]Antianginal drugs: Nitrates, β-blockers, Calcium antagonists (Amlodipine, Nefedipine, Diltazem), Potassium channel activators (Nicorandil)

Invasive treatment: The most widely used invasive options for the treatment of ischemia heart disease include-

  1. PCI (Percutaneous coronary intervention) or

PTCA (Percutaneous transluminal coronary angioplasty)

  1. CABG (Coronary artery bypass grafting) surgery.

Advice to patient with stable angina:

  1. Do not smoke (if smoker).
  2. Aim at ideal body weight.
  3. Take regular exercise (exercise up to but not beyond, the point of chest pain is beneficial).
  4. Avoid sever unaccustomed exertion & vigorous exercise after a heavy meal or in very cold weather.
  5. Take sublingual Nitrate before undertaking exertion that may induce angina.

Reference:

  1. Davidson’s Principle and Practice of Medicine, 21st edition.
  2. Wikipedia the free encyclopedia.

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