Angina pectoris

Angina pectoris is the symptom complex caused by transient myocardial ischaemia and constitutes a clinical syndrome rather than a disease; it may occur whenever there is an imbalance between myocardial oxygen supply and demand . Coronary atheroma is by far the most common cause of angina; however, the symptom may also be a manifestation of other forms of heart disease, particularly aortic valve disease and hypertrophic cardiomyopathy.
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The common feature of angina is pain which is usually substernal, consisting of a feeling of heaviness with radiation to both arms or commonly to the ulnar border of the left arm. It may also radiate to the jaw, teeth, occipital region, back or epigastric region. Sometimes pain is absent and certain angina-equivalent symptoms, viz. breathlessness, fatigue or symptoms of low cardiac output may be present. The duration of the pain or equivalent symptoms is usually only a few minutes. The discomfort is typically relieved by nitroglycerine
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types of angina
stable angina unstable angina Prinzmetals angina post infarction unstable angina

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Stable angina or effort angina

Also called Heberdeens angina, it occurs on known physical effort, and is relieved with rest, standing or sublingual nitroglycerine. Pain gets aggravated in cold weather, after emotional upsets, by sexual intercourse, at high altitude and by straining at stool, use of thyroxine and smoking. It usually lasts for a few minutes. Sometimes the pain may occur at the beginning of a walk and disappear on further walking. This is known as "walk-through phenomenon" or "Wenckebachs secondwind phenomenon". Such symptoms may go on for months or years until the stable form changes to unstable angina or the individual develops myocardial infarction. In some patients anginal symptoms appear in the middle of the night and may indicate incipient left ventricular failure. The precipitating factors may be dreams causing release of catecholamines, a full urinary bladder or transient hypoglycaemia

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Precipitating factors for angina pectoris

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New York Heart Association functional classification of angina

I Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnoea or anginal pain .II Patients with cardiac disease resulting in slight limitation on physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea or anginal pain. III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnoea or anginal pain. IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.
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O/E

Physical examination in patients with angina pectoris is often normal. However, there may be indication of coronary risk factors like xanthelasma or xanthomas. Palpation may reveal thickened arteries and reduced or absent pulses as signs of generalised atherosclerosis. LV enlargement, S3 or S4 gallop, or a murmur of mitral regurgitation due to old myocardial infarction may be present. During an anginal episode an atrial or ventricular gallop or a systolic murmur due to transient papillary muscle dysfunction may be heard. Rarely, evidence of pulmonary congestion may be transiently present. The optic fundus may show arteriovenous nicking as evidence of hypertension. Other cause of angina like aortic stenosis, aortic regurgitation, anaemia, thyroid disease need to be ruled out.

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INVESTIGATIONS

1. X-ray chest for cardiomegaly or pulmonary congestion. 2. Lipid profile 3. Blood sugar, serum uric acid and urine examination Electrocardiogram : In 50% of patients with angina, the resting ECG is normal between anginal episodes. In others, evidence of old myocardial infarction, ST-T changes or intraventricular conduction abnormalities like left or right bundle branch block may be present. During an anginal episode transient ST-T depression may be noted which disappears with rest or with sublingual nitroglycerine or nifedipine. In Prinzmetals angina the ST segment is elevated during angina. Stress testing : It is the most widely used test for IHD. Using a treadmill or bicycle ergometer, a 12-lead ECG is recorded before, during and following exercise. Thallium stress testing : The results of exercise testing can be enhanced by intravenous injection of the radioisotope thallium 201 to assess regional myocardial perfusion using a gamma camera.

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Echocardiography and Doppler studies : These studies provide information regarding ventricular ejection fraction, regional wall motion abnormalities, LV thrombus and mitral regurgitation. Stress echocardiography is presently being utilised to identify regional wallmotion abnormalities immediately after exercise, as a marker for exercise-induced myocardial ischaemia. IV dobutamine infusion can be administered to see the wall-motion abnormalities in those who cannot exercise. Coronary angiography : In combination with LV angiography, coronary angiography has become the gold standard for the diagnosis of atherosclerotic coronary heart disease. It identifies the location and the severity of atherosclerotic disease and can determine the most suitable type of therapy, i.e. medical, surgical or coronary angioplasty. (For indications refer chapter on angiocardiography

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DIFFERENTIAL DIAGNOSIS

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MANAGEMENT
The goals of therapy are to 1. prolong life, 2. improve quality of life, 3. prevent myocardial infarction and 4. improve effort tolerance.

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a.Explanation of the nature of illness and reassurance : Explain to the patient and the family the reasons for the development of angina, how to avoid precipitating factors, and the availability of methods of treatment, viz. drugs, surgery and coronary angioplasty, which can improve the quality of life and, in some selected patients, prolong life .b.Risk factor modification : Weight reduction, serum lipid normalisation by prudent diet and drugs, effective diabetes control by diet and drugs, and avoiding oral contraceptives in female patients have all been shown to favourably modify the course of IHD. Smoking as a risk factor needs to be specially stressed .
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.c.Treatment of coexisting conditions, viz. anaemia, hypertension and hypo- or hyperthyroidism .d.Modification of activity : Physical activity should be modified to maintain the balance between the myocardial O2 supply and demand. Physical effort which precipitates angina should be avoided, especially after a meal. Bed rest is not required for stable angina. All patients except those employed in manual work should be encouraged to carry out their normal activities. Strenuous physical or mental work may need modification.e. Drug treatment : During an anginal attack, cessation of physical activity and 0.5 mg of sublingual nitroglycerine or 5 mg sublingual isosorbide nitrate will abolish the attack in most patients.

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Mechanical revascularisation

(i) Percutaneous transluminal coronary angioplasty (PTCA): This is indicated in single-, double- and at times triple-vessel disease. Best results are achieved with proximal, discrete, noncalcified lesions in patients with angina of fairly recent onset, usually of less than 1 year duration. Lately, atherectomy devices, lasers and stents have been used to dilate vessels not amenable to dilatation by balloon catheter. (ii) Coronary artery bypass surgery : The procedure gives excellent relief of angina when compared with medical treatment and in some patients, especially those with left main coronary artery obstruction, triple-vessel disease and proximal left anterior descending disease and patients with reduced ejection fraction and angina, it increases life expectancy more as compared to medical treatment.

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Unstable angina

Also called intermediate coronary syndrome and preinfarction angina, it is a serious form of angina and needs special attention since 20% of these patients are likely to develop fatal or nonfatal myocardial infarction within 4 months. There is a higher incidence of left main coronary artery disease in these patients. Unstable angina includes
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Unstable angina includes

(i) angina of recent onset (less than 60 days); (ii) stable angina with symptoms more severe in intensity, frequency or duration and more easily provoked; (iii) angina at rest; (iv) angina following myocardial infarction (within days or weeks). ST-T depression in the ECG is common. Occasionally, transient ST elevation may be noted. In-hospital mortality in this subset of patients is high. About 25% of these patients have coronary artery thrombosis. In the others, spasm plays an important role.
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Management

Patients with unstable angina should be admitted in an ICU and managed with bed rest, oxygen, sedation with morphine or pethidine Treatment of precipitating factors like anaemia, diabetes, fever or hypertension. Continuous ECG monitoring should be done to detect possible development of myocardial infarction. Arrhythmias should be treated effectively.
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Prinzmetal angina

Also called variant angina, it was described by Prinzmetal in 1959. The pain usually occurs at rest at night or in the early morning hours. It is associated with ST elevation on the ECG, responds to sublingual nitroglycerine or nifedipine, It is caused by spasm of the coronary artery. The episodes of pain may be accompanied by various grades of AV block and other arrhythmias.
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Exercise stress testing may fail to induce ischaemic changes. The spasm can be induced by smoking, hyperventilation or by ergonovine injection. The cause of spasm may be increased alphaadrenergic activity during the early morning hours or platelet aggregation. Coronary angiography may reveal normal coronary arteries. However, more than 50% of patients have associated severe coronary artery obstructive disease.
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Post infarction angina

Some patients with myocardial infarction develop angina 2 days to 8 weeks following the acute infarction. Most patients have multivessel disease or partially recanalised coronary arteries with residual myocardial ischaemia. Management requires early coronary angiography to delineate the coronary artery anatomy and appropriate treatment (PTCA or CABG surgery if required).
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Homoeopathic management
CHEST - ANGINA pectoris AM-C, APIS , ARG-N, ARN, ARS, AUR, AUR-M, CACT, CHININ-AR, MED, NAJA, OX-AC, PHOS, RHUS-T, SPIG, SPONG.

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ANGINAPECTORIS
Presented by Dr Arun krishnan TP I MD(Organon)

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