Angina Pectoris: Causes, Symptoms, Diagnosis, and Modern Treatment Options

Angina Pectoris: Causes, Symptoms, Diagnosis, and Modern Treatment Options

Question. Write short note on angina pectoris.
Or
Describe clinical features, diagnosis and management of angina pectoris.
Or
Outline the management of angina pectoris.

Answer. Angina pectoris is a symptom complex caused by transient myocardial ischemia and constitutes a clinical syndrome rather than a disease.

Types

1. Stable
2. Unstable
3. Nocturnal
4. Prinzmetal’s
5. Postinfarction angina

Angina Pectoris: Causes, Symptoms, Diagnosis, and Treatment

Etiology

Acute myocardial ischemia occurs when myocardial oxygen demand exceeds supply in following:

1. Coronary atherosclerotic narrowing (most cases).
2. Non­atherosclerotic coronary artery disease—Coronary spasm, coronary thromboembolism, congenital anomalies, coronary vasculitis.
3. Valvalar heart disease — Aortic stenosis and/or aortic regurgitation, mitral stenosis with pulmonary hypertension, mitral valve prolapse.
4. Pulmonary hypertension.
5. Systemic hypertension.
6. Hvpertrophic or dilated cardiomyopathy.
7. Anemia—from tachycardia and reduction in O2 availability.

Symptoms and Causes of Angina Pectoris

Precipitating Causes

1. Physical exertion
2. Heavy metal
3. Exposure to cold
4. Emotion and excitement
5. Hyperinsulinism in diabetic patients
6. Other causes: Straining at stools, bathing, sexual intercourse,micturition

Clinical Features Angina Pectoris

Symptoms Angina Pectoris

1. Anginal pain:

1. Site: Most often over middle or lower sternum or over left precordium, at times in epigastrium. Sometimes discomfort is located only in left shoulder or left upper arm, occasionally in lower jaw and rarely in interscapular area.
2. Radiation of pain: May spread to right or left arm or both neck or jaw. Occasionally, pain starts in the wrist, upper arms or face and then spreads to the chest.
3. Character: Vice­like constriction or choking. Sometimes only pressure or burning pain, rarely mere weakness of one or both arms. An important characteristic is its constancy, the pain being steady while it lasts.
4. Duration: Most commonly l to 4 minutes. It may force patient to stop walking.
5. Provocation: By effrt specially like walking against the wind or up a climb, hurrying after meals or unaccustomed exercise at times due to excitement anger, and fear. In advanced cases, pain is provoked by lying down (angina decubitus) or stooping.
6. Relief with sublingual nitroglycerine.

Angina Pectoris Diagnosis and Modern Treatment

2. Dyspnea: If it occurs before the pain suggests severe ventricular disease.

3. Other symptoms:

1. Choking sensation in throat or feeling of impending doom.
2. Belching or passage of fltus or polyuria after an attck.
3. Dizziness, faintness or rarely syncope
4. If pain is severe sweating and nausea.

Signs Angina Pectoris

1. At time, no signs are present.

2. Signs ofLV dysfunction: Atrial or third heart sound.

3. Dysfunction of papillary muscle: It can lead to transient mitral regurgitation in case of ischemia.

4. Signs associated with risk factors:

1. Hypertension.
2. Hyperlipidemia—Arcus senilis, xanthelasma, or cholesterol deposits along tendons and in skin of palms and buttcks.
3. Obesity
4. Diabetes and its accompaniments.

5. During the attck—pallor and sweating with rise of BP often tachycardia.
Pressure on carotid sinus may produce slowing of pulse and cessation of pain.

Diagnosis Angina Pectoris

Investigations Angina Pectoris

1. Resting ECG: ECG changes of myocardial ischemia are reflcted in ST-T waves. Occassionally, there is flttning of T waves in some lead in patient with angina.
2. Exercise ECG or stress test: With continuous ECG monitoring and intermittent BP recording is performed with a treadmill or bicycle ergometer. Standardized protocols are used (e.g. Bruce protocol), enabling performance to be assessed in same patient at diffrent times and workload at onset of symptoms or ECG changes to be determined.
   An exercise ECG is abnormal, if there is horizontal or down­sloping ST segment depression of 0.1 mm or more in any lead.
3. Myocardial perfusion scintigraphy: The isotope cardiovascular stress (usually thallium­201 or technetium—99 m) is injected at peak exercise and images taken with a camera immediately or shortly after exercise and compared with rest images taken a few hours later following a second injection of tracer.
   Areas of myocardial ischemia are identifid by reduced isotopic uptake in the same anatomical distribution stress images but not resting images (reversible defect).
4. Coronary angiography: It is done before angioplasty or coronary bypass surgery.

Modern Treatment Options for Angina Pectoris

Management Angina Pectoris

1. It is divided into three phases:
2. General measures.
3. Pharmacological treatment.
4. Invasive treatment.

General Measures Angina Pectoris

1. Do not smoke
2. Aim at ideal body weight
3. Take regular exercise
4. Avoid severe exertion, vigorous exercise and exercise in cold weather
5. Take sublingual nitrate before taking exertion that may induce angina.

Pharmacological treatment Angina Pectoris

Following agents are used with successful outcome.

1. Antiplatelet agents:

1. Aspirin is used usually in dose of 75–150 mg daily.
2. Clopidogrel is used along with or without aspirin at dose of 75 mg daily.

2. Anti-anginal agents:

1. Sublingual glycertrinitrate effctively abort anginal attack by causing coronary vasodilatation and reducing preload and cardiac output.
2. Beta-blockers improve cardiac effiency and reduce oxygen consumption. Cardioselective agents such as atenolol 25 to 50 mg, metoprolol 200 mg daily can be used.
3. Calcium­channel antagonists, i.e. amlodipine, lacidipine. They are the vasodilators and lowers myocardial oxygen demand by reducing blood
   pressure and myocardial contractility.
4. Potassium­channel opener, i.e. nicorandil has atrial and venous dilatation property which does not exhibit tolerance.

Invasive Treatment Angina Pectoris

1. *Percutaneous coronary *intervention or percutaneous transluminal coronary *angioplasty is done.
2. Coronary artery bypass grafting is done.