Angina

9 November, 2023 admin 0 Comments

Angina pectoris, commonly known as angina, is severe chest pain due to ischemia (a lack of blood, hence a lack of oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart’s blood vessels). Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries. The term derives from the Latin angina (“infection of the throat”) from the Greek ἀγχόνη ankhone (“strangling”), and the Latin 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 heart attack, and a heart attack can occur without pain).

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 herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack.

What causes Angina (Chest pain)?

The most common cause of angina is coronary artery disease. A less common cause of angina is spasm of the coronary arteries.

Coronary artery disease

Coronary arteries supply oxygenated blood to the heart muscle. Coronary artery disease develops as cholesterol is deposited in the artery wall, causing the formation of a hard, thick substance called cholesterol plaque. The accumulation of cholesterol plaque over time causes narrowing of the coronary arteries, a process called arteriosclerosis. Arteriosclerosis can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. When coronary arteries become narrowed by more than 50% to 70%, they can no longer meet the increased blood oxygen demand by the heart muscle during exercise or stress. Lack of oxygen to the heart muscle causes chest pain (angina).

Coronary artery spasm

The walls of the arteries are surrounded by muscle fibers. Rapid contraction of these muscle fibers causes a sudden narrowing (spasm) of the arteries. A spasm of the coronary arteries reduces blood to the heart muscle and causes angina. Angina as a result of a coronary artery spasm is called “variant” angina or Prinzmetal angina. Prinzmetal angina typically occurs at rest, usually in the early morning hours. Spasms can occur in normal coronary arteries as well as in those narrowed by arteriosclerosis.

Coronary artery spasm can also be caused by use/abuse of cocaine. The spasm of the artery wall caused by cocaine can be so significant that it can actually cause a heart attack.

Other causes of chest pain

In caring for patients with chest pain, the doctor distinguishes whether the pain is related to a lack of oxygen to the heart muscle (as in angina or heart attack), or is due to another process. Many conditions are considered that can cause chest pain which is similar to that of a heart attack or angina. Examples include the following:

Pleuritis (pleurisy): Inflammation of the lining of the lungs (pleuritis) causes sharp chest pain, which is aggravated by deep breathing and coughing. Patients often notice shortness of breath, in part due to their shallow breathing to minimize chest pain. Viral infections are the most common causes of pleurisy. Other systemic inflammatory conditions, such as systemic lupus, can also cause pleurisy.
Pericarditis: Pericarditis is inflammation of the lining around the heart. Symptoms of pericarditis are similar to that of pleuritis.
Pneumonia: Pneumonia (bacterial infection of the lung) causes fever and chest pain. Chest pain in bacterial pneumonia is due to an irritation or infection of the lining of the lung (pleura).
Pulmonary embolism: blood clots travel from the veins of the pelvis or the lower extremities to the lung, the condition is called pulmonary embolism. Pulmonary embolism can cause death of lung tissue (pulmonary infarction). Pulmonary infarction can lead to irritation of the pleura, causing chest pain similar to pleurisy. Some common causes of blood clots in these veins is deep vein thrombosis (prolonged immobility, recent surgery, trauma to the legs, or pelvic infection).
Pneumothorax: Small sacs in the lung tissue (alveoli) can spontaneously burst, causing pneumothorax. Symptoms of pneumothorax include sudden, severe, sharp chest pain and shortness of breath. One common cause of pneumothorax is severe emphysema.
Mitral valve prolapse: Mitral valve prolapse is a common heart valve abnormality, affecting 5% to 10% of the population. MVP is especially common among women between 20 to 40 years of age. Chest pain with MVP is usually sharp but not severe. Unlike angina, chest pain with MVP rarely occurs during or after exercise, and usually will not respond to nitroglycerin.
Aortic dissection: The aorta is the major vessel delivering blood from the left ventricle to the rest of the body. Aortic dissection (tearing of the aorta wall) is a life-threatening emergency. Aortic dissection causes severe, unrelenting chest and back pain. Young adults with aortic dissection usually have Marfan’s syndrome, an inherited disease in which an abnormal form of the structural protein called collagen causes weakness of the aortic wall. Older patients develop aortic dissection typically as a result of chronic, high blood pressure, in addition to generalized hardening of the arteries (arteriosclerosis).
Costochondritis, rib fractures, muscle strain or spasm: Pain originating from the chest wall may be due to muscle strain or spasm, costochondritis, or rib fractures. Chest wall pain is usually sharp and constant. It is usually worsened by movement, coughing, deep breathing, and direct pressure on the area. Muscle spasm and strain can result from vigorous, unusual twisting and bending. The joints between the ribs and cartilage next to the breastbone can become inflamed, a condition called costochondritis. Fractured ribs resulting from trauma or cancer involvement can cause significant chest pain.
Nerve compression: Compression of the nerve roots by bone spurs as they exit the spinal cord can cause pain. Nerve compression can also cause weakness and numbness in the upper arm and chest.
Shingles (herpes zoster infection of the nerves): Shingles is nerve irritation from the infection, which can cause chest pain days before any typical rash appears.
Esophageal spasm and reflux: The esophagus is the long muscular tube connecting the mouth to the stomach. Reflux, or regurgitation of stomach contents and acid into the esophagus can cause heartburn and chest pain. Spasm of the muscle of the esophagus can also cause chest pain which can be indistinguishable from chest pain caused by angina or a heart attack. The cause of esophageal muscle spasm is not known. Pain of esophageal spasm can respond to nitroglycerin in a similar manner as angina.
Gallbladder attack (gallstones): Gallstones can block the gallbladder or bile ducts and cause severe pain of the upper abdomen, back and chest. Gallbladder attacks can mimic the pain of angina and heart attack.
Anxiety and panic attacks: Anxiety, depression, and panic attacks are frequently associated with chest pain lasting from minutes to days. The pain can be sharp or dull. It is usually accompanied by shortness of breath, or the inability to take a deep breath. Emotional stress can aggravate chest pain, but the pain is generally not related to exertion, and is not relieved by nitroglycerin. These patients often breath too fast (hyperventilate), causing lightheadedness, numbness, and tingling in the lips and fingers. Coronary artery disease risk factors are typically absent in these patients. Since there is no test for panic attacks, patients with chest pain usually undergo tests to exclude coronary artery disease and other causes of chest pain.

What are the Risk Factors?

Age (≥ 55 yo for men, ≥ 65 for women)
Cigarette smoking
Diabetes mellitus (DM)
Dyslipidemia
Family History of premature Cardiovascular Disease(men <55 yo, female <65)
Hypertension (HTN)
Kidney disease (microalbuminuria or GFR<60 mL/min)
Obesity (BMI ≥ 30 kg/m2)
Physical inactivity

Conditions that exacerbate or provoke angina

Medications
vasodilators
excessive thyroid replacement
vasoconstrictors

polycythemia which thickens theblood causing it to slow its flow through the heart muscle

Smoking

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. Additionally, CDC reports that the risk of CHD, stroke, and PVD 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 who had quit smoking compared to those who continued. Studies have found that there are short term and long term benefits to smoking cessation.

What are the Symptoms of Angina (Chest pain)?

A wide range of health problems can cause chest pain. In many cases, the underlying cause has nothing to do with your heart — though there’s no easy way to tell without seeing a doctor.

Chest pain related to cardiac problems
In general, chest pain related to a heart attack or another heart problem is associated with one or more of the following:

Pressure, fullness or tightness in your chest
Crushing or searing pain that radiates to your back, neck, jaw, shoulders and arms, especially your left arm
Pain that lasts more than a few minutes, goes away and comes back or varies in intensity
Shortness of breath, sweating, dizziness or nausea

Chest pain related to noncardiac problems
Chest pain that isn’t related to a heart problem is more often associated with:

A burning sensation behind your breastbone (sternum)
A sour taste or a sensation of food re-entering your mouth
Trouble swallowing
Pain that gets better or worse when you change your body position
Pain that intensifies when you breathe deeply or cough
Tenderness when you push on your chest

When to see a doctor
If you have new or unexplained chest pain or suspect you’re having a heart attack, call for emergency medical help immediately. Don’t waste time trying to diagnose heart attack symptoms yourself.

Every minute is crucial if you’re having a heart attack. A trip to the emergency room could save your life — or bring you peace of mind if nothing is seriously wrong with your health.

Don’t drive yourself to the hospital, unless you have no other option. Driving yourself puts you and others at risk if your condition suddenly worsens.

Classification

Stable angina

Also known as effort angina, this refers to the more common understanding of angina related to myocardial ischemia. Typical presentations 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. Symptoms typically abate several minutes following cessation of precipitating activities and resume when activity resumes. In this way, stable angina may be thought of as being similar to claudication symptoms.

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.

It has at least one of these three features:

it occurs at rest (or with minimal exertion), usually lasting >10 min;
it is severe and of new onset (i.e., within the prior 4–6 weeks); and/or
it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously).

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. The process starts with atherosclerosis, and when inflamed leads to an active plaque, which undergoes thrombosis and results in acute ischemia, which finally results in cell necrosis after calcium entry. Studies show that 64% of all unstable anginas occur between 10 PM and 8 AM when patients are at rest.

In stable angina, the developing atheroma is protected with a fibrous cap. This cap (atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and further decrease the lumen of the coronary vessel. This explains why an unstable angina appears to be independent of activity.

Microvascular angina

Microvascular Angina or Angina Syndrome X is characterized by angina-like chest pain, but have different causes.The cause of Microvascular Angina is unknown, but it appears to be the result of poor function in the tiny blood vessels of the heart, arms and legs. Since microvascular angina isn’t characterized by arterial blockages, it’s harder to recognize and diagnose, but its prognosis is excellent.

Diagnosis

The electrocardiogram (EKG) is a recording of the electrical activity of the heart muscle, and can detect heart muscle which is in need of oxygen. The EKG is useful in showing changes caused by inadequate oxygenation of the heart muscle or a heart attack.

Exercise stress test

In patients with a normal resting EKG, exercise treadmill or bicycle testing can be useful screening tools for coronary artery disease. During an exercise stress test (also referred to as stress test, exercise electrocardiogram, graded exercise treadmill test, or stress ECG), EKG recordings of the heart are performed continuously as the patient walks on a treadmill or pedals on a stationary bike at increasing levels of difficulty. The occurrence of chest pain during exercise can be correlated with changes on the EKG, which demonstrates the lack of oxygen to the heart muscle. When the patient rests, the angina and the changes on the EKG which indicate lack of oxygen to the heart can both disappear. The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%. If the exercise stress test does not show signs of coronary artery disease, a nuclear agent (thallium) can be given intravenously during exercise stress test. The addition of thallium allows nuclear imaging of blood flow to different regions of the heart, using an external camera. A reduced blood flow in an area of the heart during exercise, with normal blood flow to the area at rest, signifies significant artery narrowing in that region of the heart.

Stress echocardiography

Stress echocardiography combines echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing. Like the exercise thallium test, stress echocardiography is more accurate than an exercise stress test in detecting coronary artery disease. When a coronary artery is significantly narrowed, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle during exercise. Abnormalities in muscle contraction can be detected by echocardiography. Stress echocardiography and thallium stress tests are both about 80% to 85% accurate in detecting significant coronary artery disease.

When a patient cannot undergo exercise stress test because of neurological or orthopedic difficulties, medications can be injected intravenously to simulate the stress on the heart normally brought on by exercise. Heart imaging can be performed with a nuclear camera or echocardiography.

Cardiac catheterization

Cardiac catheterization with angiography (coronary arteriography) is a technique that allows x-ray pictures to be taken of the coronary arteries. It is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the coronary arteries. Iodine contrast “dye” is injected into the arteries while an x-ray video is recorded. Coronary arteriography gives the doctor a picture of the location and severity of coronary artery disease. This information can be important in helping doctors select treatment options.

CT coronary angiogram

CT coronary angiography is procedure that uses an intravenous dye that contains iodine, and CT scanning to image the coronary arteries. While the use of catheters is not necessary (thus the term “noninvasive” test applies to this procedure), there are still some risks involved, including the following:

Patients allergic to iodine
Patients with abnormal kidney function
Radiation exposure which is similar to, if not greater than, that received with a conventional coronary angiogram.

Nonetheless, this is generally a very safe test for most people. It is a major tool in the diagnosis of coronary artery disease in patients:

at high risk for developing coronary disease (cigarette smokers, those with genetic risk, high cholesterol levels, hypertension, or diabetes),
who have unclear results with exercise stress tests or other testing, or
who have symptoms suspicious of coronary disease

Methods of Treatment

Cardiac causes

If it appears that heart problems are the cause of your chest pain, your doctor may give you medications such as:

Aspirin. Aspirin inhibits blood clotting, helping to maintain blood flow through narrowed heart arteries. When taken during a heart attack, aspirin can significantly decrease death rates. You may be asked to chew the aspirin to hasten its absorption. Aspirin is recommended for most people who have had a heart attack.
Nitroglycerin. This medication for treating angina temporarily widens narrowed blood vessels, improving blood flow to and from your heart.
Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications help limit the amount of damage during a heart attack and prevent a second heart attack.
Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that’s blocking blood flow to your heart. These drugs are most effective when taken within an hour after symptoms of a heart attack begin.
Ranolazine (Ranexa). This is a relatively new drug for treating chronic angina. It’s used only when other anti-anginal drugs haven’t worked because it can cause a heart problem known as QT prolongation, which can increase your risk of heart rhythm problems. It should be used with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs allow blood to flow from your heart more easily. Your doctor may prescribe ACE inhibitors or ARBs if you’ve had a moderate to severe heart attack that has reduced your heart’s pumping capacity. These drugs also lower blood pressure and may prevent a second heart attack.
Calcium channel blockers. When treating coronary artery spasm, doctors sometimes use heart medications such as calcium channel blockers to relax the coronary arteries and prevent spasm.

Heart attack treatments

If it’s clear you’re having a heart attack, you may be treated with clotbusting drugs or undergo a surgical procedure such as:

Angioplasty and stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — doctors insert a catheter with a special balloon into a blocked coronary artery. The balloon is inflated to open up the artery and restore blood flow to your heart. Then, a small wire mesh coil (stent) is usually inserted to keep the artery open. Many people will go straight from the emergency room to the catheterization laboratory to have angioplasty performed as quickly as possible.
Coronary bypass surgery. This procedure creates an alternative route for blood to go around a blocked coronary artery.

Angina treatment

Doctors usually first treat angina with medication. You’ll likely start receiving medication in the emergency room, including aspirin, nitroglycerin, beta blockers and blood thinners.

If you have unstable angina — chest pain while you’re at rest — you may need immediate coronary catheterization followed by angioplasty and stenting. In some cases, you may need coronary bypass surgery.

Treatment for other cardiovascular conditions

Other heart and lung conditions can be treated initially in the emergency room. If it’s clear you’re experiencing a pulmonary embolism, you’ll likely be treated with emergency blood-thinning medications, sometimes including clotbusting medications (thrombolytics).

Aortic dissection often requires emergency surgery.

Noncardiac causes

If emergency room doctors determine you’re out of immediate danger, you may be referred to your own physician or a specialist for further evaluation. Treatments for noncardiac causes of chest pain depend on the type of problem. These problems and their treatments include:

Heartburn. If your symptoms suggest heartburn, you’ll likely need to take an over-the-counter or prescription-strength stomach acid blocker or antacid in the emergency room. Most episodes of heartburn are isolated events caused by overeating or by eating fatty foods.

If you experience frequent heartburn (at least one episode a week), your doctor or a doctor who specializes in stomach and intestinal problems (gastroenterologist) may ask you to undergo more tests. Left untreated, chronic, frequent heartburn can occasionally lead to scarring and narrowing of your esophagus. Treatment for chronic heartburn may include dietary modifications, antacids, acid blockers or other prescription medications and, in some cases, surgery.

Panic attack. This anxiety-related cause of chest pain can be treated with prescription anti-anxiety medications, relaxation techniques and counseling to find out what may be triggering your attacks. Panic attacks are often mistaken for heart attacks, and many people are seen in emergency rooms for this problem. But once your condition is diagnosed, you can be referred for treatment to help you gain control over these attacks.
Pleurisy. This inflammation of the pleura, the membrane that lines your chest cavity and covers your lungs, may result from a variety of conditions, including pneumonia and, rarely, autoimmune conditions such as lupus. Your doctor will want to identify and treat the underlying disease that caused pleurisy. Over-the-counter pain relievers can help minimize the pain until the inflammation subsides.
Costochondritis. Treatment for this inflammation of the cartilage of your rib cage is generally rest, heat and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others).
Sore muscles, injured ribs or pinched nerves. Chest pain from injured ribs, pinched nerves and sore chest muscles improves with time and self-care measures recommended by your doctor.
Swallowing disorders. These disorders have many causes, which can usually be treated with medications, minor surgery or endoscopic techniques. You’ll probably be referred to a gastroenterologist for evaluation and treatment.
Shingles. Treatment with acyclovir (Zovirax) or a similar antiviral medication is best started as quickly as possible, preferably within 24 hours from the onset of pain or burning, and before the appearance of blisters. Doctors use other treatments, such as analgesics and antihistamines, to control symptoms such as pain and itching.
Gallbladder or pancreas problems. You may need surgery to treat an inflamed gallbladder or pancreas that’s causing pain to radiate from your abdomen into your chest.

Chest pain can be one of the most difficult symptoms to interpret. But spending time in the ER having your chest pain evaluated can bring you peace of mind, and may even save your life.

Drugs rating:

	Title	Votes	Rating
1	Ranexa (Ranolazine)	1		(10.0/10)
2	Lovenox (Enoxaparin)	29		(8.9/10)
3	Aspirin	4		(8.8/10)
4	Corgard (Nadolol)	2		(8.5/10)
5	Cardizem (Diltiazem)	12		(8.4/10)
6	Tenormin (Atenolol)	52		(7.7/10)
7	Nifedical XL (Nifedipine)	18		(7.7/10)
8	Tiazac (Diltiazem)	8		(7.5/10)
9	Caduet (Amlodipine and Atorvastatin)	26		(7.2/10)
10	Toprol XL (Labetalol)	242		(7.1/10)
11	Lopressor (Metoprolol)	40		(7.0/10)
12	Cartia XT (Diltiazem)	21		(7.0/10)
13	Inderal (Propranolol)	236		(6.9/10)
14	Coreg (Carvedilol)	72		(6.8/10)
15	Metoprolol	47		(6.6/10)
16	Metoprolol Succinate ER (Metoprolol)	2		(6.5/10)
17	Norvasc (Amlodipine)	337		(6.4/10)
18	Calan (Verapamil)	22		(5.7/10)
19	Taztia XT (Diltiazem)	4		(4.5/10)
20	Isordil (Isosorbide dinitrate)	0		(0/10)
21	Sorbitrate (Isosorbide dinitrate)	0		(0/10)
22	Integrilin (Eptifibatide)	0		(0/10)
23	Fragmin (Dalteparin)	0		(0/10)
24	Verelan (Verapamil)	0		(0/10)
25	Isochron (Isosorbide dinitrate)	0		(0/10)
26	Diltia XT (Diltiazem)	0		(0/10)
27	Afeditab CR (Nifedipine)	0		(0/10)
28	Cardene (Nicardipine)	0		(0/10)
29	Dilatrate-SR (Isosorbide Dinitrate Extended-Release)	0		(0/10)
30	Dilacor XR (Diltiazem)	0		(0/10)
31	Diltzac (Diltiazem)	0		(0/10)
32	Covera-HS (Verapamil)	0		(0/10)
33	Minitran (Nitroglycerin)	0		(0/10)
34	Isoptin (Verapamil)	0		(0/10)
35	Blocadren (Timolol)	0		(0/10)
36	Angiomax (Bivalirudin)	0		(0/10)
37	Nitrek (Nitroglycerin)	0		(0/10)
38	Nitro-Time (Nitroglycerin)	0		(0/10)
39	NitroQuick (Nitroglycerin)	0		(0/10)
40	NitroMist (Nitroglycerin lingual aerosol)	0		(0/10)
41	Nitrogard (Nitroglycerin)	0		(0/10)
42	Nitrocot (Nitroglycerin)	0		(0/10)
43	Nitrostat (Nitroglycerin)	0		(0/10)

Epidemiology

Roughly 6.3 million Americans are estimated to experience angina. 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. 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, as chronicled in The China Study, has already led to an increase in angina and related diseases in countries such as China.

Recently, angina was tied to exposure of Bisphenol-A among adults in the US.

Drugs Expert