Angina Pectoris (Anginal Pain)

Angina pectoris[1]

Angina pectoris, also known as angina, is a condition characterized by feeling of chest pain. It occurs due to development of ischemia of heart muscles. It occurs due to decrease in supply of blood to the heart. 


Presentation

Development of retrosternal chest discomfort is the classical symptom of angina pectoris. Retrosternal chest discomfort is characterized by feeling of heaviness, pressure, choking or burning sensation in the chest. The areas where the pain is experienced are the back, neck, epigastrium, jaw or shoulders. In some cases, the pain may radiate to the arms, neck and shoulders.

Angina pectoris develops during physical exertion such as exercise, cold climate or extreme psychological stress. The pain lasts for about 1 – 5 minutes and is relieved only by administration of nitroglycerin. The pain, which lasts for just about few seconds, is not angina pectoris. In angina pectoris, the intensity of the pain does not change with respiration, cough or by changing one’s position.

Individuals with angina pectoris, also suffer from breathlessness, fatigue, dizziness, sweating, and nausea [6].

Workup

The following tests are employed for diagnosing angina pectoris:

Electrocardiogram: This is done to check for blood flow to the heart or to detect a heart attack.

Stress test: In this test, the heart functioning of the individual is monitored during stress. The individual is asked to walk on a treadmill, and the heart rate is monitored through ECG during exercise.

Nuclear stress test: In nuclear stress tests, the individual is not asked to undergo physical exercise, instead a radioactive substance is injected, and heart functioning monitored subsequently [7].

Angiography: In this method, a dye is injected into the body, and x-ray machine takes several images that would provide detailed information about the blood vessels.

Treatment

Nictroglycerin remains the major treatment regime for angina pectoris. It is a vasodilator that increases the oxygen supply to the heart. In addition, beta blockers and calcium channel blockers are also indicated in the treatment of angina pectoris. Another class of drugs, known as If inhibitors, such as ivabradine, is also administered to patients with angina pectoris [8].

In patients who have been suffering from narrowed arteries; balloon angioplasty is considered, which is a method that helps in widening the arteries. If severe blockage is detected, then by pass surgery is opted for.

Once the symptoms have been brought under control, then the individuals are advised to make certain life style changes, and are also given various medications, which may have to be taken on a long term basis [9].

Lifestyle changes such as decreasing weight, avoiding smoking and adopting relaxation techniques to keep stress at bay are advised. Angina pectoris is also triggered by exertion, and therefore, individuals are also advised to take rest and breaks in between.

Prognosis

Prognosis of the condition is not favorable with adverse outcomes, such as development of unstable angina, myocardial infarction and death. With advancing age, the condition may worsen, and the severity of the symptoms may also increase. However, those with stable angina and 3-vessel disease, the prognosis of the condition are good if the ventricular function is normal [5].

Etiology

Reduced blood supply to the heart can cause development of angina pectoris. The various factors, that are responsible for triggering such attacks, include the following:

Age: Men aged 45 years and above, and women aged 55 years and above, are at an increased risk of developing angina pectoris.

Diseases: Certain underlying disease conditions, such as diabetes mellitus, dyslipidemia, hypertension, family history of cardiovascular disorders, obesity and kidney diseases, all increase the risk of developing angina pectoris.

Stress: Prolonged duration of psychological stress is yet another factor that can cause angina pectoris.

Lifestyle habits: Cigarette smoking and physical inactivity, also significantly increases the risk of developing angina pectoris. A research study postulated the fact that, individuals who smoke and have coronary artery disease, suffer from increased level of sympathetic nerve activity [2].

Epidemiology

It has been estimated that in the US, about 9.8 million individuals suffer from angina every year. In addition to this, approximately 500,000 new cases crop up annually. Statistics have also revealed that, every 25 seconds, an American will suffer from a coronary event, and every minute someone will die from it. In the year 2005, about 232,115 males and 213,572 females lost lives due to coronary artery disease [3].

Sex distribution
Age distribution

Pathophysiology

The imbalance between the heart’s demand for oxygen-rich blood, and its supply, causes angina pectoris to set in. Development of myocardial ischemia causes the myocardial cells to switch, from aerobic to anaerobic metabolism, which in turn gives rise to injury of the metabolic and electrical functions. Such a phenomenon favors the development of angina pectoris.

Angina pectoris is a classical symptom of myocardial ischemia. The increase in demand of blood supply can occur in conditions of heavy physical activity, such as exercises or in cases of atherosclerosis, which causes narrowing of the arteries, due to plaque buildup.

Research has revealed that, adenosine is the main chemical mediator for angina. In conditions of myocardial ischemia, adenosine triphosphate is degraded to adenosine, which in turn causes dilation of arterial blood vessels, which finally leads to angina pain [4].

Prevention

The following steps can be adopted to prevent angina pectoris [10]:

  • Reducing stress levels
  • Keeping weight under check
  • Eating healthy diet low in fat and cholesterol and high in fiber and other nutrients
  • Avoiding smoking
  • Keeping other disease conditions such as hypertension and diabetes under control

Summary

It is an acute problem that needs prompt medical intervention. Angina pectoris is a relatively common condition that can occur due to several factors. An imbalance that occurs between the demand for oxygen, and myocardial blood supply, triggers the onset of angina pectoris. The condition is a common complain amongst individuals, who have developed coronary artery disease [1].

Patient Information

Definition: Angina pectoris is a condition, characterized by development of discomfort in the chest. Such a kind of discomfort is defined as feeling of fullness, heaviness, pressure and choking sensation in the chest.

Cause: Imbalance between the heart’s demand for blood and the supply causes angina pectoris to develop. This condition is a common occurrence amongst individuals, who have developed myocardial ischemia.

Symptoms: Symptoms of angina pectoris include development of discomfort in the chest, and pain in the shoulders, neck, jaws. Individuals also experience dizziness, sweating, fatigue, breathlessness and nausea.

Diagnosis: Preliminary physical examination of the signs, followed by blood tests and echocardiogram are carried out. Once the condition of the patient is stabilized, stress test, nuclear stress test and angiography are also indicated.

Treatment: Angina pectoris is treated with nitroglycerin, which works by increasing the oxygen supply to the heart. In addition, beta and calcium channel blockers are also administered. In patients with narrowed arteries, balloon angioplasty is considered, or in severe cases, bypass surgery is indicated.

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References

  1. Foreman RD. Mechanisms of cardiac pain. Annu Rev Physiol 1999; 61:143.
  2. Campbell AR, Satran D, Zenovich AG, Campbell KM, Espel JC, Arndt TL. Enhanced external counterpulsation improves systolic blood pressure in patients with refractory angina. Am Heart J. Dec 2008;156(6):1217-22.
  3. Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. Jan 27 2009;119(3):e21-181.
  4. Crea F, Pupita G, Galassi AR, et al. Role of adenosine in pathogenesis of anginal pain. Circulation. Jan 1990;81(1):164-72
  5. Kannel WB, Feinleib M. Natural history of angina pectoris in the Framingham study. Prognosis and survival.Am J Cardiol. Feb 1972;29(2):154-63
  6. Cook DG, Shaper AG. Breathlessness, angina pectoris and coronary artery disease. Am J Cardiol 1989; 63:921.
  7. O'Keefe JH Jr, Barnhart CS, Bateman TM. Comparison of stress echocardiography and stress myocardial perfusion scintigraphy for diagnosing coronary artery disease and assessing its severity. Am J Cardiol. Apr 13 1995;75(11):25D-34D.
  8. Fox K, Ford I, Steg PG, et al. Ivabradine for patients with stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a randomised, double-blind, placebo-controlled trial. Lancet 2008; 372:807.
  9. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators.N Engl J Med. Jan 20 2000;342(3):145-53.
  10. Deedwania PC, Carbajal EV. Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation. Mar 1990;81(3):748-56.

Media References

  1. Angina pectoris, CC BY-SA 3.0

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