Angina Pectoris

Notes
  • Angina is a symptom of coronary artery disease (CAD).
  • It occurs as a result of myocardial ischemia that is brought about by an imbalance between myocardial blood supply and oxygen demand (where the demand exceeds supply).
  • In Angina Pectoris, myocardial ischemia generally occurs without infarction (i.e. without thrombus or embolus).
  • Atherosclerotic arterial narrowing tends to vary with time of the day, with greatest narrowing being in the morning hence more people are likely to experience angina at this time.
Symptoms
  • Mild to severe discomfort (described as pressure, heaviness, squeezing, burning, choking or painful sensation) mainly beneath the sternum
  • The angina pain or discomfort may spread to the left shoulder, inside of the left (or sometimes right) arm, fingers, back, throat, jaws, teeth, and upper abdomen.
  • Positive Cossio-Levine's sign for angina (where a patient uses entire palm or the clenched fist of the right arm held over the chest to describe ischemic chest pain).

##Symptoms are largely related to the type of angina, of which there are two main types:

  • In stable angina (or effort angina or classic angina), the relationship between workload and ischemia is generally directly proportional. Pain or discomfort typically fade off several minutes after activity and recur when activity resumes. Physical examination findings in most cases are normal.
  • Unstable or “crescendo” angina occurs at rest or with minimal exertion, lasts longer and occurs with a crescendo pattern. It is clinically a worsening angina that may soon culminate into a heart attack. It tends to happen more often in older adults.
  • In atypical angina, angina may present itself with uncharacteristic symptoms such as bloating, gas and abdominal distress) may occur in some patients.
  • Angina decubitus, which is a variant of angina pectoris that occurs at night while the patient is lying flat, may occur.
  • Microvascular Angina (or Cardiac syndrome X) is a type of angina that is caused by spasms within the walls of the heart’s smallest coronary arteries.This type of angina causes more severe and longer lasting symptoms of angina such as chest pain, shortness of breath and fatigue.
  • Prinzmetal's angina (or "variant" angina) is a temporary coronary vasospastic state that can occur locally in either a normal or diseased vessel. It is closely associated with vasospastic disorders (e.g. Raynaud's phenomenon and migraine headaches).
Diagnosis
  • Clinical review
  • ECG (with and without stress)
  • Stress testing (not for Prinzmetal's angina that is rather diagnosed by use of IV ergonovine where the symptoms are rapidly elevated but reversed by Nitroglycerine)
  • Coronary angiography
  • CXR (any possibility of cardiomegaly, cardiomyopathy or pulmonary edema??)
Differential
  • Acute gastritis
  • Acute Pericarditis
  • Angina Pectoris
  • Diabetes
  • Dilated Cardiomyopathy
  • Esophageal spasm
  • Hiatal Hernia
  • Hypertension
  • Hypertensive Heart Disease
  • Myocardial Ischemia
  • Myocarditis
  • Peptic Ulcer Disease / GERD
  • Pulmonary Embolism
  • Thromboangiitis Obliterans
  • Varicella-Zoster Virus
Prevention

##Treatment of underlying conditions or risk factors such as:

  • Hypercholesterolemia
  • Hypertension
  • Lack of body exercises
  • Obesity
  • Smoking
  • Alcoholism
Management

## Statins (HMG-CoA reductase inhibitor) to lower LDL cholesterol levels

  • Atorvastatin
  • Simvastatin
  • Fluvastatin
  • Pravastatin
  • Rosuvastatin

##Antiplatelets

  • Aspirin
  • Clopidogrel
  • Dipyridamole
  • Ticlopidine

##Beta-blockers to reduce symptoms of angina (by reducing heart rate and contractility and consequently oxygen demand):

  • Acebutolol
  • Atenolol
  • Bisoprolol
  • Carvedilol
  • Labetalol
  • Metoprolol
  • Pindolol
  • propranolol

##Calcium channel blockers(mostly used together with Beta-blockers):

  • Nifedipine
  • Nicardipine
  • Felodipine
  • Amlodipine
  • Verapamil 
  • Diltiazem

##Nitrates (dilate coronary arteries reducing venous return and cardiac load thus relieving angina)

  • Sublingual nitroglycerin (effective for an acute attack)
  • Isosorbide dinitrate
  • Isosorbide-5-mononitrate
  • Transdermal nitroglycerin

##ACE inhibitors and angiotensin II receptor blockers (useful in CAD patients with left ventricle dysfunction)

  • Captopril
  • Enalapril
  • Fosinopril
  • Lisinopril
  • Perindopril
  • Ramipril
  • Trandolapril
  • Candesartan
  • Irbesartan
  • Losartan
  • Telmisartan
  • Valsartan

##Other measures

  • Heparin
  • Oxygen in serious cases
  • Angioplasty Stent
  • Coronary artery bypass grafting (CABG)
  • Proper diet
  • Reduction of salt intake
  • Body exercises
  • Management of underlying illness like diabetes and hypertension
  • Treatment of obesity
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