Angina

Symptom complex resulting from mismatch of myocardial (muscles of heart) oxygen demand and supply.

Classic angina: A sense of choking or of pressure or heaviness deep to the left side of chest, usually brought on by exertion or anxiety and relieved by rest.

Anginal equivalent: Exertional breathlessness or exertional  fatigue, which results from myocardial ischemia and is relieved by rest or nitroglycerin.

Variant angina: Also called Prinzmetal angina: occurs at rest or in atypical patterns (e.g., after
exercise or nocturnally); is caused by coronary artery spasm and is associated with ECG changes (usually ST elevation) during symptoms.

Unstable angina: Pain that is new or is changed in character (more frequent, more severe, or both)
Portends myocardial infarction (heart attack) in a certain percentage of patients.

GENERAL PREVENTION

  • Discontinue tobacco
  • Adhere to low fat/low cholesterol diet
  • Maintain regular aerobic exercise program
  • Antilipidemics if prescribed
  • Daily aspirin in patients with indications

EPIDEMIOLOGY

Predominant age: Most common in middle-aged and older men, postmenopausal women
Predominant sex: Male > female
Family history of premature coronary artery disease (CAD)

  • Hypercholesterolemia
  • Hypertension
  • Tobacco abuse
  • Diabetes mellitus
  • Male gender
  • Advanced age
  • Morbid obesity
  • Hyperhomocystenemia (possibly)
  • Genetics
  • Coronary artery disease has genetic implications.

ETIOLOGY / CAUSES

  • Atherosclerosis of the coronary arteries
  • Coronary artery spasm
  • Aortic stenosis
  • Hypertrophic cardiomyopathy
  • Severe hypertension
  • Aortic insufficiency
  • Primary pulmonary hypertension
  • ASSOCIATED CONDITIONS
  • Hypercholesterolemia
  • Claudication, peripheral vascular disease
  • Arterial aneurysms
  • Mitral regurgitation
  • Papillary muscle dysfunction
  • Ventricular aneurysm
  • Abdominal aortic aneurysm
  • Hypertrophic subaortic stenosis
  • Primary hyperthyroidism
  • Pernicious anemia and other high output states

DIAGNOSIS

SIGNS AND SYMPTOMS

  • Chest pressure or heaviness, radiating to the back, neck, or arms, brought on by exertion
  • emotional stress, meals, cold air, or smoking, and relieved by rest or nitrates
  • Discomfort may radiate to the neck, lower jaw, teeth, shoulders, and inner aspects of the arms or back.
  • Discomfort may be described with a clenched fist over the sternum (Levine’s sign).
  • Dyspnea on exertion may present as the only symptom.
  • A choking sensation on exertion is a classic symptom.
  • Atypical symptoms more likely in women, elderly, and diabetic patients.

SIGNS AND SYMPTOMS

ECG – May show evidence of ischemia or prior myocardial infarction. Other findings are
nonspecific and are frequently normal. – Bundle branch block, Wolff-Parkinson-White
syndrome or intraventricular conduction delay may make the ECG unreliable.
Troponin !

Treadmill Test / Exercise stress testing

Stress echocardiography

Lab

Lipid Profile :
Total cholesterol: Frequently elevated
HDL cholesterol: Frequently reduced
LDL cholesterol: Frequently elevated

CRP: Elevation between 3–10 may indicate increased risk for CAD.

Homocysteine : May be elevated

  • Imaging
  • Radionuclide scintigraphy
  • Stress scintigraphy
  • Coronary angiography

DIAGNOSTIC PROCEDURES/SURGERY

Definitive evaluation and therapy involves coronary arteriography, necessary for confirmation and delineation of coronary disease, and direction of interventional therapy or surgery. Coronary artery stenting has proven very effective, with restenosis rates (in skilled hands) often below 10%, eliminating need for surgery in many cases. Surgery in CAD not amenable to intervention has proven to have a long-term benefit.

DIFFERENTIAL DIAGNOSIS –  Conditions to be differentiated from :

  • Gastro esophageal reflux disease
  • Esophageal spasm
  • Peptic ulcer disease
  • Gastritis or non-ulcer dyspepsia
  • Cholecystitis
  • Costochondritis
  • Pericarditis
  • Aortic dissection
  • Pleurisy
  • Pulmonary embolus
  • Pulmonary hypertension
  • Pneumothorax
  • Radiculopathy
  • Shoulder arthropathy
  • Psychological: Anxiety and panic disorders

TREATMENT

GENERAL MEASURES

The patient’s symptoms should be brought under control medically. If symptoms are unstable, hospitalization is warranted.

Treatment goal -involves reducing myocardial oxygen demand or increasing oxygen supply Noninvasive testing is often indicated as a means of stratifying the patient’s risk for an event that might seriously compromise myocardial function.

  • Quit smoking
  • Minimize emotional stress
  • Diet
  • Low fat, low cholesterol, low salt diet
  • Activity
  • As tolerated after consulting physician
  • Exercise program after physician’s approval; very effective if consistent

SURGERY

Coronary artery bypass graft surgery, angioplasty, stent placement, atherectomy in selected cases

COMPLICATIONS

  • Related to myocardial damage occurring during infarction
  • Arrhythmia
  • Cardiac arrest
  • Congestive heart failure
  • PATIENT MONITORING
  • Depends on the frequency and severity of the complaints
  • Hospitalization is indicated in patients diagnosed with unstable angina.