Angina

Angina
Specialty	Cardiology

This is about chest pain due to oxygen shortage in the heart. For angina tonsillaris see tonsillitis. For the infection of the soft tissues in the floor of the mouth, see Ludwig's angina.

Angina pectoris is chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels). Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries. The term derives from the Greek ankhon ("strangling") and the Latin pectus ("chest"), and can therefore be translated as "a strangling feeling in the chest".

It is common to equate severity of angina with risk of fatal cardiac events. There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle ie there can be severe pain with little or no risk of a heart attack, and a heart attack can occur without pain)

Worsening ("crescendo") angina attacks, sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms of unstable angina (usually grouped with similar conditions as the acute coronary syndrome). As these may herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack.

Symptoms

Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms, shoulders, and neck. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina.

Myocardial ischemia comes about when the myocardia (the heart muscles) fail to take in sufficient blood and oxygen to function correctly. This inadequate perfusion of blood and the resulting reduced delivery of oxygen and nutrients, is directly correlated to blocked or narrowed blood vessels.

Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous system) such as nausea, vomiting and pallor.

Major risk factors for angina include family history of premature heart disease, cigarette smoking, diabetes, high cholesterol, and high blood pressure.

A variant form of angina (Prinzmetal's angina) occurs in patients with normal coronary arteries or insignificant atherosclerosis. It is thought to be caused by spasms of the artery. It occurs more in younger women.

Diagnosis

In patients with the occasional angina who are not having chest pain, an electrocardiogram (ECG) is typically normal, unless there have been other cardiac problems in the past. During pain, depression or elevation of the ST segment may be observed. To elicit these changes, an exercise ECG test ("treadmill test") may be performed, during which the patient exercises to their maximum ability before fatigue, breathless or, importantly, pain supervenes; if characteristic ECG changes are documented (typically more than 1 mm of flat or downsloping ST depression), the test is considered diagnostic for angina. The exercise test is also useful in looking for other markers of myocardial ischaemia: blood pressure response (or lack thereof, particularly a drop in systolic pressure), dysrhythmia and chronotropic response. Other alternatives to a standard exercise test include a thallium scintigram (in patients that cannot exercise enough for the purposes of the treadmill tests, e.g., due to asthma or arthritis or in whom the ECG is too abnormal at rest) or Stress Echocardiography.

In patients in whom such noninvasive testing is diagnostic, a coronary angiogram is typically performed to identify the nature of the coronary lesion, and whether this would be a candidate for angioplasty, coronary artery bypass graft (CABG), treatment only with medication, or other treatments. In patients who are in hospital with unstable angina (or the newer term of "high risk acute coronary syndromes"), those with resting ischaemic ECG changes or those with raised cardiac enzymes such as troponin may undergo coronary angiography directly.

Pathophysiology

Increase in heart rate result in increased oxygen demand by the heart. The heart has a limited ability to increase its oxygen intake during episodes of increased demand. Therefore, an increase in oxygen demand by the heart (eg, during exercise) has to be met by a proportional increase in blood flow to the heart.

Myocardial ischemia can result from:

1. a reduction of blood flow to the heart caused by the stenosis or spasm of the heart's arteries
2. resistance of the blood vessels
3. reduced oxygen-carrying capacity of the blood.

Atherosclerosis is the most common cause of stenosis (narrowing of the blood vessels) of the heart's arteries and, hence, angina pectoris. Some people with chest pain have normal or minimal narrowing of heart arteries; in these patients, vasospasm is a more likely cause for the pain, sometimes in the context of Prinzmetal angina and syndrome X.

Myocardial ischemia also can be the result of factors affecting blood composition, such as reduced oxygen-carrying capacity of blood, as seen with severe anemia (low number of red blood cells), or long-term smoking.

Epidemiology

Roughly 6.3 million Americans are estimated to experience angina. Angina is more often the presenting symptom of coronary artery disease in women than in men. The prevalence of angina rises with an increase in age. Similar figures apply in the remainder of the Western world. All forms of coronary heart disease are much less-common in the Third World, as its risk factors are much more-common in Western and Westernized countries; it could therefore be termed a disease of affluence. The increase of smoking, obesity and other risk factors has already led to an increase in angina and related diseases in countries such as China.

Treatment

The main goals of treatment in angina pectoris are relief of symptoms, slowing progression of the disease, and reduction of future events, especially heart attacks and of course death. An aspirin (75 mg to 100 mg) per day has been shown to be beneficial for all patients with stable angina that have no problems with its use. Beta-blockers have a large body of evidence in morbidity and mortality benefits (fewer symptoms and disability and live longer) and short-acting nitroglycerin medications are used for symptomatic relief of angina. Calcium channel blockers (such as nifedipine and amlodipine), Isosorbide mononitrate and nicorandil are vasodilators commonly used in chronic stable angina. A new therpaeutic class, called If inhibitor, has recently been made available: ivabradine, the first If inhibitor provides pure heart rate reduction with anti-ischemic and antianginal efficacy maintainde over time.ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit and lastly, statins are the most frequently used lipid/cholesterol modifiers which probably also stabilise existing atheromatous plaque.

Surprising perhaps is that exercise is also a very good long term treatment for angina[1](but only particular regimes - gentle and sustained exercise rather than dangerous intense short bursts), probably working by complex mechanisms such improving blood pressure and promoting coronary artery collateralisation.

Identifying and treating risk factors for further coronary heart disease is a priority in patients with angina. This means testing for elevated cholesterol and other fats in the blood, diabetes and hypertension (high blood pressure), encouraging stopping smoking and weight optimisation.

Even though known victims may wear a necklace or bracelet identifying the medical condition, EMS (ambulance) is still required.

Ranolazine(Ranexa) is a new class of anti anginal drug that was approved by the Food and Drug Administration (FDA)

Recently, University of Cincinnati medical researchers in cardiology have tried to use a non-invasive, non-surgical collecting tool to gather harvested erythropoietic bone marrow-based adult stem cells and coax them into regrowing new coronary blood vessels to supply the cardiac muscle's cells (cardiac myocytes) with oxygenated blood, with some success- leading to larger Phase 2 trials.

External links

• British Heart Foundation - Angina
• Angina Pectoris Online Resource for nurses and those in similar professions.