Angina
Description of Medical Condition
Symptom complex resulting from mismatch of myocardial oxygen demand and supply
• Classic angina — a sense of choking or of pressure or heaviness deep to the precordium, usually brought on by exertion or anxiety and relieved by rest.
• Anginal equivalent — exertional dyspnea or exertional fatigue which results from myocardial ischemia and is relieved by rest or nitroglycerin
• Variant angina — also referred to as Prinzmetal angina describes angina occurring at rest of atypical patterns such as after exercise or nocturnally. Prinzmetal angina is caused by coronary artery spasm and is associated with ECG changes (usually ST elevation) during symptoms
• Unstable angina — pain which is new or which is changed in character to become more frequent, more severe or both. Unstable angina portends myocardial infarction in a certain percentage of patients.
System(s) affected: Cardiovascular
Genetics: Coronary artery disease has genetic implications.
Incidence/Prevalence in USA: The presenting symptom of coronary artery disease in 38% of men and 61% of women.
Predominant age: Most common in middle age and older men; postmenopausal women
Predominant sex: Male > Female
Medical Symptoms and Signs of Disease
• Precordial pressure or heaviness, radiating to the back, neck or arms, brought on by exercise, emotional stress, meals, cold air or smoking, and relieved by rest or nitrates
• Discomfort may radiate to neck, lower jaw, teeth, shoulders, inner aspects of the arms or back
• Discomfort may be described with a clinched 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
What Causes Disease?
• Atherosclerosis of the coronary arteries
• Coronary artery spasm
• Aortic stenosis
• Hypertrophic cardiomyopathy
• Severe hypertension
• Aortic insufficiency
• Primary pulmonary hypertension
Risk Factors
• Family history of premature coronary artery disease (CAD)
• Hypercholesterolemia
• Hypertension
• Tobacco abuse
• Diabetes mellitus
• Male gender
• Advanced age
• Morbid obesity
Diagnosis of Disease
Differential Diagnosis
• Esophagitis (GERD)
• Esophagealspasm
• Peptic ulcer disease
• Gastritis
• Cholecystitis
• Costochondritis
• Pericarditis
• Aortic dissection
• Pleurisy
• Pulmonary embolus
• Pulmonary hypertension
• Pneumothorax
• Radiculopathy
• Shoulder arthropathy
• Psychological — anxiety and panic disorders
Laboratory
• Total cholesterol — frequently elevated
• HDL cholesterol — frequently reduced
• LDL cholesterol — frequently elevated
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
Pathological Findings
Atherosclero sis of the coronary arteries
Special Tests
• ECG — may show evidence of ischemia or prior myocardial infarction. Other findings are nonspecific and tracings are frequently normal. Bundle branch block. Wolff-Parkinson-White syndrome or intraventricular conduction delay may make the ECG unreliable.
• Exercise stress testing
Imaging
• Radionuclide scintigraphy
• Stress echocardiography
• Stress scintigraphy
• Coronary angiography
Diagnostic Procedures
• Rapid sequence MRI may show coronary artery calcification and thereby identify coronary artery disease. It does not identify obstructive coronary lesions however.
• 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 long term benefit.
Treatment (Medical Therapy)
Appropriate Health Care
The patient’s symptoms should be brought under control medically. If symptoms are unstable, hospitalization is warranted.
General Measures
• Treatment goal — involves reducing myocardial oxygen demand or to increase 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
Surgical Measures
Coronary artery bypass graft surgery, angioplasty, stent placement, atherectomy in selected cases
Activity
• As tolerated after consulting physician
• Exercise program after physician’s approval; very effective if consistent
Diet
Low fat, low cholesterol diet
Patient Education
American Heart Association, 7320 Greenville Avenue, Dallas, TX 75231, (214)373-6300
Medications (Drugs, Medicines)
Drug(s) of Choice
• Aspirin, 81-325mgqd
• Beta-blockers: atenolol 25-100 mg qd, metoprolol 25-100 mg bid or bisoprolol 2.5-10 mg day. Beta-blockers are effective in reducing heart rate and thereby decreasing oxygen consumption and reducing angina. Adjust doses according to the clinical response. Aim to maintain resting heart rate of 50-60 beats per minute. Side effects are infrequent but include fatigue, erectile dysfunction, exacerbation of peripheral vascular and obstructive pulmonary disease, depression.
• Nitroglycerin 0.4 mg SL is the most effective therapy for acute anginal episodes. Repeat 2-3 times over a 10-15 minute time period; if no relief patient should seek immediate medical attention.
• Long acting nitrates (mononitrates ortransdermal nitrates): should be used with a drug free interval of 10-14 hours to prevent tolerance. Tachyphylaxis occurs rapidly. Act through preload reduction and coronary vasodilatation. Side effects which include headaches and hypotension, tend to clear with continued usage. A beta-blocker or calcium channel blocker should be used in conjunction with the nitrates during the drug free interval.
• Long acting calcium channel blockers: verapamil 160-480 mg qd or diltiazem 90-360 mg qd or nifedipine 30-120 mg qd or amlodipine 5-20 mg qd. The various agents have their own individual side effects (i.e., verapamil — constipation; nifedipine — peripheral edema).
• HMC CoA reductase inhibitors (e.g., atorvastatin, pravastatin, lovastatin) for hypercholesterolemia. These drugs decrease incidence of symptomatic CAD, and reduce both myocardial infarction and death from Ml
• Heparin: low molecular weight heparin should be initiated in patients hospitalized with unstable angina
• Combination therapy: especially nitrates plus calcium antagonists with or without beta-blockers may be used.
Contraindications:
• Sildenafil (Viagra) with nitrates should be avoided due to hypotension and possible death
Precautions:
• Avoid verapamil and diltiazem with compromised ventricular function (left ventricular ejection fraction < 40%) especially in conjunction with beta-blockers.
Significant possible interactions:
• Combination therapies may impair LV function and precipitate heart failure
• Beta-blockers and calcium channel blockers
– May combine to produce symptomatic heart block although either class of drug may act alone in producing this side effect
• Niacin may worsen glucose intolerance
Alternative Drugs
• Lipid lowering drugs are often initiated in patients with unfavorable lipid profiles, whether symptomatic from CAD or not
• Consider adding clopidogrel (Plavix) to ASA for severe diffuse CAD
Patient Monitoring
• Depends on the frequency and severity of the complaints
• Hospitalization is indicated in patients diagnosed with unstable angina
Prevention / Avoidance
• Discontinue tobacco, adherence to low fat/low cholesterol diet, regular aerobic exercise program
• Anti-lipidemics
Possible Complications
• Related to myocardial damage occurring during infarction
• Arrhythmia
• Cardiac arrest
• Congestive heart failure
Expected Course / Prognosis
• Variable and depending on the extent of coronary artery disease as well as left ventricular function
• Annual mortality is 3-4% overall
Miscellaneous
Associated Conditions
• Hypercholesterolemia
• Claudication
• Peripheral vascular occlusion 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
Age-Related Factors
Pediatric: Suspect familial dyslipidemias in children presenting with manifestations of coronary artery
Geriatric: Patients may be very sensitive to the side effects of medications (i.e., beta-blockers — depression)
Pregnancy
– their diagnosis should be excluded and the patient managed closely by an obstetrician and cardiologist as the metabolic demands of pregnancy will exacerbate symptoms and directly interfere with treatment
Synonyms
• Heberden syndrome
h4>International Classification of Diseases
411.1 Intermediate coronary syndrome
413 Angina pectoris
413.1 Prinzmetal angina
413.9 Other and unspecified angina pectoris
See Also
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