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Angina Pectoris

Anginal Pain

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].

Dyspnea
  • We present the case of a 43-year-old male who was initially evaluated for angina pectoris and dyspnea.[ncbi.nlm.nih.gov]
  • The patient was admitted to our hospital because of dyspnea and pretibial edema 7 years after the diagnosis of variant angina.[ncbi.nlm.nih.gov]
  • Pulmonary embolism should be suspected when dyspnea or tachypnea seems to be disproportionate to the severity of the chest pain. Diffuse esophageal spasm is the extracardiac condition that is confused most often with ischemic cardiac chest pain.[ncbi.nlm.nih.gov]
  • Cardiopulmonary status is evaluated for evidence of tachypnea, dyspnea, diaphoresis, pulmonary crackles, bradycardia or tachycardia, altered pulse strength, the appearance of a third or fourth heart sound or mid- to late-systolic murmurs over the apex[medical-dictionary.thefreedictionary.com]
Pain
  • The pharyngeal pain was similar to acute pharyngitis with burning pain.[ncbi.nlm.nih.gov]
  • Chest pain and electrocardiographic changes were resolved after administration of coronary dilator and coronary stenting, but shoulder pain persisted. At 6 hours after stenting, left hemiparesis was found with deteriorated shoulder pain.[ncbi.nlm.nih.gov]
  • This is the first example of angina-like chest pain which definitively resulted from a midoesophageal diverticulum. Therefore, midoesophageal diverticula should be considered as a rare differential diagnosis of exercise-induced retrosternal pain.[ncbi.nlm.nih.gov]
  • Symptoms of Stable Angina The pain or discomfort: Occurs when the heart must work harder, usually during physical exertion Doesn't come as a surprise, and episodes of pain tend to be alike Usually lasts a short time (5 minutes or less) Is relieved by[heart.org]
  • Atypical chest pain is a common condition that has poor symptomatic, functional, and psychological outcomes.[ncbi.nlm.nih.gov]
Coronary Artery Disease
  • Coronary artery disease (CAD) is a major problem worldwide. As an endothelium-enriched microRNA (miRNA), miR-126 has been reported to serve as a potential biomarker of acute myocardial infarction.[ncbi.nlm.nih.gov]
  • In patients with coronary artery disease, coronary collateral circulation (CCC) develops as an adaptation to ischemia and contributes toward reduction of cardiovascular events.[ncbi.nlm.nih.gov]
  • Syntax score (SS), which is an angiographic tool used in grading the complexity of coronary artery disease (CAD), has prognostic importance in coronary artery disease (CAD) and provides important information regarding selection of revascularization strategy[ncbi.nlm.nih.gov]
  • The patient underwent urgent coronary angiography, which revealed no significant coronary artery disease. Echocardiography showed noncompaction of the left ventricular myocardium.[ncbi.nlm.nih.gov]
  • Patients with type 1 coronary microvascular dysfunction (i.e. absence of epicardial coronary artery disease and myocardial disease) should receive strict control of their cardiovascular risk factors and thus receive statins and ACE-inhibitors in most[ncbi.nlm.nih.gov]
Arm Pain
  • Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.[icd10data.com]
  • NIH: National Heart, Lung, and Blood Institute Definition (NCI) Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.[fpnotebook.com]
  • ) Pain in the chest and/or arm which tends to be severe and intermittent Cold limbs Cyanosis of lips and nails T: Dark red with purple spots or Purple body C: Little P: Minute (scarcely perceptible) and thready or Knotted Treatment Principle Clear Yang[americandragon.com]
Dutch
  • At 1month post-PCI, patients completed the Dutch version of the Hospital Anxiety and Depression Scale (HADS).[ncbi.nlm.nih.gov]
  • Estenocardia German ANGINA PECTORIS , Anginabeschwerden , ischaemischer Brustschmerz , Anginasyndrom , Angina , Anginaschmerz , ANGINA PECTORIS SYNDROM , Angina pectoris, nicht naeher bezeichnet , HERZSCHMERZEN , Angina pectoris , Angor pectoris , Stenokardie Dutch[fpnotebook.com]
Abdominal Pain
  • pain Dizziness Tinnitus Lumbago Edema Abdominal pain with edema during pregnancy due to Blood Deficiency and abnormal water circulation Oliguria Palpitations Cold feet Extreme coldness of the hands and feet Vertigo Weakness and numbness of lower back[americandragon.com]
  • ., adj an ginal. herpes angina ( angina herpe tica ) herpangina . intestinal angina generalized cramping abdominal pain occurring shortly after a meal and persisting for one to three hours, due to ischemia of the smooth muscle of the bowel. angina pec[medical-dictionary.thefreedictionary.com]
  • Examples of non-cardiac related causes of chest pain are: Infections Lung trauma or tumors Gastric reflux Upper abdominal pain From Reviewed on 11/20/2017 Sources: Patient Comments & Reviews CONTINUE SCROLLING FOR RELATED ARTICLE[emedicinehealth.com]
  • Women may also experience symptoms such as: Nausea Shortness of breath Abdominal pain Discomfort in the neck, jaw or back Stabbing pain instead of chest pressure When to see a doctor If your chest pain lasts longer than a few minutes and doesn't go away[mayoclinic.org]
Jaw Pain
  • Common symptoms of angina pectoris include: Uncomfortable pressure in the chest Fullness or squeezing sensation around the heart area Pain in the center of the chest Jaw pain Back pain Shoulder or neck pain Not all chest pain is heart-related.[brookhavenheart.com]
  • Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.[icd10data.com]
  • NIH: National Heart, Lung, and Blood Institute Definition (NCI) Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.[fpnotebook.com]
  • But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.[wexnermedical.osu.edu]
Periodontitis
  • Dental infections, such as periodontitis, associate with atherosclerosis and its complications.[ncbi.nlm.nih.gov]
Poor Oral Hygiene
  • We studied a cohort followed-up since 1985 for incidence of angina pectoris with the hypothesis that calculus accumulation, proxy for poor oral hygiene, links to this symptom.[ncbi.nlm.nih.gov]
Chest Pain
  • Atypical chest pain is a common condition that has poor symptomatic, functional, and psychological outcomes.[ncbi.nlm.nih.gov]
  • They had typical chest pain at rest, and a significant vasospasm of coronary arteries with chest pain and obvious ST-T changes in the electrocardiograms was provoked by intracoronary injection of acetylcholine in both patients.[ncbi.nlm.nih.gov]
  • CONCLUSIONS This case demonstrated that agenesis left circumflex artery although presenting with severe symptoms, such as chest pain, is a benign finding. Chest pain was not correlated to perfusion defects in this case.[ncbi.nlm.nih.gov]
  • Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease . It occurs when the heart muscle doesn't get as much blood as it needs.[heart.org]
  • CFVR was not associated with chest pain characteristics or results from diagnostic stress testing.[ncbi.nlm.nih.gov]
Heart Disease
  • Recently, high-intensity aerobic interval training was shown to be more effective than continuous moderate-intensity exercise for improving maximal aerobic capacity and endurance in patients with coronary heart disease.[ncbi.nlm.nih.gov]
  • Intractable angina pectoris affects approximately 5% to 15% of patients with ischemic heart disease. Current treatment options for refractory angina can be divided into 3 groups: pharmacological, nonpharmacological noninvasive, and invasive.[ncbi.nlm.nih.gov]
  • Stable angina pectoris (SAP) is one of the most common symptoms of coronary heart disease. Chinese herbal medicine (CHM) has been used to treat SAP increasingly due to its less side effects.[ncbi.nlm.nih.gov]
  • Definition (CHV) chest pain caused by coronary heart disease Definition (CHV) chest pain caused by coronary heart disease Definition (CHV) chest pain caused by coronary heart disease Definition (CHV) chest pain caused by coronary heart disease Definition[fpnotebook.com]
  • Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority.[ncbi.nlm.nih.gov]
Exertional Chest Pain
  • In addition, there was no exertional chest pain, and treadmill exercise electrocardiographic results were negative. This finding was confirmed by coronary computed tomographic angiography.[ncbi.nlm.nih.gov]
Carotid Bruit
  • Look for physical signs of abnormal lipid metabolism (eg, xanthelasma, xanthoma) or of diffuse atherosclerosis (eg, absence or diminished peripheral pulses, increased light reflexes or arteriovenous nicking upon ophthalmic examination, carotid bruit).[emedicine.medscape.com]
Shoulder Pain
  • Chest pain and electrocardiographic changes were resolved after administration of coronary dilator and coronary stenting, but shoulder pain persisted. At 6 hours after stenting, left hemiparesis was found with deteriorated shoulder pain.[ncbi.nlm.nih.gov]
  • .- ) back pain ( M54.9 ) breast pain ( N64.4 ) chest pain ( R07.1- R07.9 ) ear pain ( H92.0- ) eye pain ( H57.1 ) headache ( R51 ) joint pain ( M25.5- ) limb pain ( M79.6- ) lumbar region pain ( M54.5 ) pelvic and perineal pain ( R10.2 ) shoulder pain[icd10data.com]
  • […] reported by patients with angina commonly includes the following: Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking sensation) as opposed to frank pain Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders[emedicine.medscape.com]
Neck Pain
  • Common symptoms of angina pectoris include: Uncomfortable pressure in the chest Fullness or squeezing sensation around the heart area Pain in the center of the chest Jaw pain Back pain Shoulder or neck pain Not all chest pain is heart-related.[brookhavenheart.com]
  • Symptoms Symptoms of angina vary but typically include: A pressing, squeezing or crushing pain, usually in the chest underneath the breastbone or in the upper back, the arms or neck Pain radiating in the arms, shoulders, jaw, neck or back from the chest[wexnermedical.osu.edu]
Back Pain
  • Common symptoms of angina pectoris include: Uncomfortable pressure in the chest Fullness or squeezing sensation around the heart area Pain in the center of the chest Jaw pain Back pain Shoulder or neck pain Not all chest pain is heart-related.[brookhavenheart.com]
  • .- ) back pain ( M54.9 ) breast pain ( N64.4 ) chest pain ( R07.1- R07.9 ) ear pain ( H92.0- ) eye pain ( H57.1 ) headache ( R51 ) joint pain ( M25.5- ) limb pain ( M79.6- ) lumbar region pain ( M54.5 ) pelvic and perineal pain ( R10.2 ) shoulder pain[icd10data.com]
Increased Sweating
  • Angina typically causes uncomfortable pressure in the chest, neck, jaw, shoulders, or back, fullness or a squeezing sensation in the center of the chest, increased sweating, and shortness of breath.[mytherapyapp.com]

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.

Hypertriglyceridemia
  • Postprandial hypertriglyceridemia and hyperglycemia may promote endothelial and hemorheological dysfunction.[ncbi.nlm.nih.gov]
  • […] syndrome has been characterized by the presence of hyperinsulinemia (fasting glucose level, 100 mg/dL), abdominal obesity (waist circumference, 40 in for men or 35 in for women), decreased HDL cholesterol levels ( 40 mg/dL for men or 50 mg/dL for women), hypertriglyceridemia[emedicine.medscape.com]
T Wave Inversion
  • Additionally, DS could also further reduce the content of fibrinogen, adjust blood lipid level, correct T wave inversion, and so on. Fifteen adverse drug reactions were reported in two studies, Four of which appeared in the experimental group.[ncbi.nlm.nih.gov]
  • Whereas for patients who have myocardial infarction, it illustrates a T-wave inversion and ST-segment depression or elevation. 8.Angina pectoris can be confirmed using a stress test during exercise.[differencebetween.net]
  • The 12-lead electrocardiogram is monitored for ST-segment elevation or depression, T-wave inversion, and cardiac arrhythmias. A health care provider should remain with the patient and provide emotional support throughout the episode.[medical-dictionary.thefreedictionary.com]
Ischemic Changes
  • The original definition of cardiac syndrome X also mandated that ischemic changes on exercise (despite normal coronary arteries) were displayed, as shown on cardiac stress tests . [9] The primary cause of cardiac syndrome X is unknown, but factors apparently[en.wikipedia.org]

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.

References

Article

  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.

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Last updated: 2018-06-22 09:06