Angina pectoris

"Angina" redirects here. For other uses, see Angina (disambiguation).
Angina pectoris

Diagram of discomfort caused by coronary artery disease. Pressure, fullness, squeezing or pain in the center of the chest. Can also feel discomfort in the neck, jaw, shoulder, back or arm
Classification and external resources
ICD-10 I20
ICD-9 413
DiseasesDB 8695
MedlinePlus 000198 000201
eMedicine med/133
MeSH D000787

Angina pectoris – commonly known as angina – is the sensation of chest pain, pressure, or squeezing, often due to ischemia of the heart muscle from obstruction or spasm of the coronary arteries.[1] While angina pectoris can derive from anemia, cardiac arrhythmias and heart failure, its main cause is coronary artery disease, an atherosclerotic process affecting the arteries feeding the heart. The term derives from the Latin angere ("to strangle") and pectus ("chest"), and can, therefore, be translated as "a strangling feeling in the chest".

There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a myocardial infarction (heart attack) and a heart attack can occur without pain). In some cases, angina can be quite severe, and in the early 20th century this was known to be a signal of impending death.[2] However, given current medical therapies, the outlook has improved substantially. People with an average age of 62 years, who have moderate to severe degrees of angina (grading by classes II, III and IV) have a 5-year mortality rate of approximately 8%.[3]

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 precede a heart attack, they require urgent medical attention and are, in general, treated in similar fashion to myocardial infarction.

Classification

Illustration depicting angina

Stable angina

Also known as effort angina, this refers to the classic type of angina related to myocardial ischemia. A typical presentation of stable angina is that of chest discomfort and associated symptoms precipitated by some activity (running, walking, etc.) with minimal or non-existent symptoms at rest or after administration of sublingual nitroglycerin.[4] Symptoms typically abate several minutes after activity and recur when activity resumes. In this way, stable angina may be thought of as being similar to intermittent claudication symptoms. Other recognized precipitants of stable angina include cold weather, heavy meals, and emotional stress.

Unstable angina

Unstable angina (UA) (also "crescendo angina"; this is a form of acute coronary syndrome) is defined as angina pectoris that changes or worsens.[1]

It has at least one of these three features:

  1. it occurs at rest (or with minimal exertion), usually lasting 3–5 minutes
  2. it is severe and of new onset (i.e., within the prior 4–6 weeks)
  3. it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than before).

UA may occur unpredictably at rest, which may be a serious indicator of an impending heart attack. What differentiates stable angina from unstable angina (other than symptoms) is the pathophysiology of the atherosclerosis. The pathophysiology of unstable angina is the reduction of coronary flow due to transient platelet aggregation on apparently normal endothelium, coronary artery spasms, or coronary thrombosis.[5][6] The process starts with atherosclerosis, progresses through inflammation to yield an active unstable plaque, which undergoes thrombosis and results in acute myocardial ischemia, which, if not reversed, results in cell necrosis (infarction).[6] Studies show that 64% of all unstable anginas occur between 10 PM and 8 AM when patients are at rest.[6][7]

In stable angina, the developing atheroma is protected with a fibrous cap. This cap may rupture in unstable angina, allowing blood clots to precipitate and further decrease the area of the coronary vessel's lumen. This explains why, in many cases, unstable angina develops independently of activity.[6]

Cardiac syndrome X

Cardiac syndrome X, sometimes known as microvascular angina is characterized by angina-like chest pain, in the context of normal epicardial coronary arteries (the largest vessels on the surface of the heart, prior to significant branching) on angiography. The original definition of cardiac syndrome X also mandated that the patient display ischemic changes on exercise EKG (ST depressions with stress) despite normal coronary arteries.[8] The primary cause of cardiac syndrome X is unknown, but factors which appear to be involved are endothelial dysfunction and reduced flow (perhaps due to spasm) in the tiny "resistance" blood vessels of the heart.[9] Since microvascular angina is not characterized by major arterial blockages, it is harder to recognize and diagnose.[10][11][12] Microvascular angina was previously felt to be a rather benign condition, but more recent data has changed this attitude. Studies including the Women's Ischemia Syndrome Evaluation (WISE) suggest that microvascular angina is part of the pathophysiology of ischemic heart disease, perhaps explaining the higher rates of angina in women than in men, as well as their predilection towards ischemia and acute coronary syndromes in the absence of obstructive coronary artery disease.[13]

Signs and symptoms

Angina pectoris can be quite painful, but many patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain, and is due to the fact that the spinal level that receives visceral sensation from the heart simultaneously receives cutaneous sensation from parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw. 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. In this case, the pulse rate and the blood pressure increases. Chest pain lasting only a few seconds is normally not angina (such as precordial catch syndrome).

Myocardial ischemia comes about when the myocardia (the heart muscles) receive insufficient blood and oxygen to function normally either because of increased oxygen demand by the myocardia or because of decreased supply to the myocardia. This inadequate perfusion of blood and the resulting reduced delivery of oxygen and nutrients are 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 cigarette smoking, diabetes, high cholesterol, high blood pressure, sedentary lifestyle, and family history of premature heart disease.

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.[14]

Cause

Major risk factors

[15]

Routine counselling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended.[17]

Conditions that exacerbate or provoke angina
[18]

One study found that smokers with coronary artery disease had a significantly increased level of sympathetic nerve activity when compared to those without. This is in addition to increases in blood pressure, heart rate, and peripheral vascular resistance associated with nicotine, which may lead to recurrent angina attacks. In addition, the Centers for Disease Control and Prevention (CDC) reports that the risk of CHD (Coronary heart disease), stroke, and PVD (Peripheral vascular disease) is reduced within 1–2 years of smoking cessation. In another study, it was found that, after one year, the prevalence of angina in smoking men under 60 after an initial attack was 40% less in those having quit smoking compared to those that continued. Studies have found that there are short-term and long-term benefits to smoking cessation.[19][20][21][22]

Other medical problems

Other cardiac problems

Myocardial ischemia can result from:

  1. a reduction of blood flow to the heart that can be caused by stenosis, spasm, or acute occlusion (by an embolus) of the heart's arteries.
  2. resistance of the blood vessels. This can be caused by narrowing of the blood vessels; a decrease in radius.[25] Blood flow is proportional to the radius of the artery to the fourth power.[26]
  3. reduced oxygen-carrying capacity of the blood, due to several factors such as a decrease in oxygen tension and hemoglobin concentration.[27] This decreases the ability to of hemoglobin to carry oxygen to myocardial tissue.[28]

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's 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.

Pathophysiology

Angina results when there is an imbalance between the heart's oxygen demand and supply. This imbalance can result from an increase in demand (e.g., during exercise) without a proportional increase in supply (e.g., due to obstruction or atherosclerosis of the coronary arteries).

However, the pathophysiology of angina in females varies significantly as compared to males.[29] Non-obstructive coronary disease is more common in females.[30][31]

Diagnosis

Angina should be suspected in people presenting with tight, dull, or heavy chest discomfort that is:[32]

  1. Retrosternal or left-sided, radiating to the left arm, neck, jaw, or back.
  2. Associated with exertion or emotional stress and relieved within several minutes by rest.
  3. Precipitated by cold weather or a meal.

Some people present with atypical symptoms, including breathlessness, nausea, or epigastric discomfort or burping. These atypical symptoms are particularly likely in older people, women, and those with diabetes.[32]

Anginal pain is not usually sharp or stabbing or influenced by respiration. Antacids and simple analgesia do not usually relieve the pain. If chest discomfort (of whatever site) is precipitated by exertion, relieved by rest, and relieved by glyceryl trinitrate, the likelihood of angina is increased.[32]

In angina patients momentarily not feeling any chest pain, an electrocardiogram (ECG) is typically normal, unless there have been other cardiac problems in the past. During periods of 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 his/her maximum ability before fatigue, breathlessness, or pain intervenes; if characteristic ECG changes are documented (typically more than 1 mm of flat or downsloping ST depression), the test is considered diagnostic for angina. Even constant monitoring of the blood pressure and the pulse rate can lead us to some conclusion regarding the angina. The exercise test is also useful in looking for other markers of myocardial ischaemia: blood pressure response (or lack thereof, in particular a drop in systolic pressure), dysrhythmia and chronotropic response. Other alternatives to a standard exercise test include a thallium scintigram or sestamibi scintigram (in patients unable to 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. There has been research that concludes that a frequency is attained when there is increase in the blood pressure and the pulse rate. This frequency varies normally but the range is 45–50 kHz for the cardiac arrest or for the heart failure. In patients 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.

Treatment

The most specific medicine to treat angina is nitroglycerin. It is a potent vasodilator that makes more oxygen available to the heart muscle. Beta blockers and calcium channel blockers act to decrease the heart's workload, and thus its requirement for oxygen. Nitroglycerin should not be given if certain inhibitors such as Sildenafil (Viagra), Tadalafil (Cialis), or Vardenafil (Levitra) have been taken within the previous 12 hours as the combination of the two could cause a serious drop in blood pressure. Treatments for angina are balloon angioplasty, in which the balloon is inserted at the end of a catheter and inflated to widen the arterial lumen. Stents to maintain the arterial widening are often used at the same time. Coronary bypass surgery involves bypassing constricted arteries with venous grafts. This is much more invasive than angioplasty.

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 death. Beta blockers (e.g., carvedilol, propranolol, atenolol) have a large body of evidence in morbidity and mortality benefits (fewer symptoms, less disability and longer life) and short-acting nitroglycerin medications have been used since 1879 for symptomatic relief of angina.[33] Calcium channel blockers (such as nifedipine (Adalat) and amlodipine), isosorbide mononitrate and nicorandil are vasodilators commonly used in chronic stable angina. A new therapeutic class, called If inhibitor, has recently been made available: Ivabradine provides pure heart rate reduction[34] leading to major anti-ischemic and antianginal efficacy. ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit. Statins are the most frequently used lipid/cholesterol modifiers, which probably also stabilize existing atheromatous plaque. Low-dose aspirin decreases the risk of heart attack in patients with chronic stable angina, and was is part of standard treatment. However, in patients without established cardiovascular disease, the increase in haemorrhagic stroke and gastrointestinal bleeding offsets any benefits and it is no longer advised unless the risk of myocardial infarction is very high.[35]

Exercise is also a very good long-term treatment for the angina (but only particular regimens - gentle and sustained exercise rather than intense short bursts),[36] probably working by complex mechanisms such as 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), and encouraging smoking cessation and weight optimisation.

The calcium channel blocker nifedipine prolongs cardiovascular event- and procedure-free survival in patients with coronary artery disease. New overt heart failures were reduced by 29% compared to placebo; however, the mortality rate difference between the two groups was statistically insignificant.[37]

Microvascular angina in women

Aggressive risk factor modification is required for effective treatment of microvascular angina where exercise plays a major role.[38] Several other treatment strategies including b-blockers, angiotensin-converting enzyme inhibitors, ranolazine, l-arginine, statin drugs and potentially estrogen replacement therapy have been shown to relieve anginal symptoms as well as improve vascular function.[38] Nitrates may be effective for symptom relief.[38] Further studies are required to determine whether specific treatments are associated with improved survival as well as decreased symptoms.

Suspected angina

Hospital admission for people with the following symptoms is recommended, as they may have unstable angina: pain at rest (which may occur at night), pain on minimal exertion, angina that seems to be progressing rapidly despite increasing medical treatment. All people with suspected angina should be urgently referred to a chest pain evaluation service, for confirmation of the diagnosis and assessment of the severity of coronary heart disease.[39]

Epidemiology

As of 2010, angina due to ischemic heart disease affects approximately 112 million people (1.6% of the population) being slightly more common in men than women (1.7% to 1.5%).[40]

In the United States, 10.2 million are estimated to experience angina with approximately 500,000 new cases occurring each year.[4][41] Angina is more often the presenting symptom of coronary artery disease in women than in men. The prevalence of angina rises with increasing age, with a mean age of onset of 62.3 years.[42] After five years post-onset, 4.8% of individuals with angina subsequently died from coronary heart disease. Men with angina were found to have an increased risk of subsequent acute myocardial infarction and coronary heart disease related death than women. 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 adoption of a rich, Westernized diet and subsequent increase of smoking, obesity, and other risk factors has led to an increase in angina and related diseases in countries such as China.

History

The concept of Hritshoola—literally heart pain—was known to Sushruta (6th century BC).[43] Dwivedi & Dwivedi (2007)—on the condition described by Sushruta—hold that: 'It embodies all the essential components of present day definition, i.e. site, nature, aggravating and relieving factors and referral. According to him angina is chest pain which is precordial, temporary, exertional, emotional, burning like and relieved by rest. He also linked this kind of pain to obesity (medoroga).'[43]

References

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  37. ↑ Poole-Wilson, Philip A; Lubsen, Jacobus; Kirwan, Bridget-Anne; Van Dalen, Fred J; Wagener, Gilbert; Danchin, Nicolas; Just, Hanjörg; Fox, Keith AA; Pocock, Stuart J; Clayton, Tim C; Motro, Michael; Parker, John D; Bourassa, Martial G; Dart, Anthony M; Hildebrandt, Per; Hjalmarson, Åke; Kragten, Johannes A; Molhoek, G Peter; Otterstad, Jan-Erik; Seabra-Gomes, Ricardo; Soler-Soler, Jordi; Weber, Simon; Coronary disease Trial Investigating Outcome with Nifedipine gastrointestinal therapeutic system investigators (2004). "Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): Randomised controlled trial". The Lancet 364 (9437): 849–57. doi:10.1016/S0140-6736(04)16980-8. PMID 15351192.
  38. ↑ 38.0 38.1 38.2 Duvernoy, Claire S (1 November 2012). "Evolving strategies for the treatment of microvascular angina in women". Expert Review of Cardiovascular Therapy 10 (11): 1413–1419. doi:10.1586/erc.12.55. PMID 23244362.
  39. ↑ NHS Clinical Knowledge Summaries (2009) Angina - stable: suspected angina Suspected angina Date site accessed: 04/01/2009
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  42. ↑ Buckley, B. S; Simpson, C. R; McLernon, D. J; Murphy, A. W; Hannaford, P. C (2009). "Five year prognosis in patients with angina identified in primary care: Incident cohort study". BMJ 339: b3058. doi:10.1136/bmj.b3058. PMC 2722695. PMID 19661139.
  43. ↑ 43.0 43.1 Dwivedi, Girish; Dwivedi, Shridhar (2007). "Sushruta – the Clinician – Teacher par Excellence" (PDF). The Indian Journal of Chest Diseases and Allied Sciences 49: 243–4.

Further reading

External links