Angina Pectoris (angina)

Angina pectoris is a pressure like substernal chest pain occurring due to imbalance between myocardial oxygen demand and supply. Angina pectoris is considered as the primary sign of ischemic heart disease. Myocardial oxygen supply may be restricted due to obstructive atherosclerotic plaque (atherosclerosis), coronary artery spasm or non-coronary problem such as acute anemia or hypotension. The anginal chest pain usually radiates to the ulnar border of the left arm. Rarely it may radiate to jaw, teeth, occipital region, back or epigastric region. In this article we are going to discuss angina pectoris, causes, types, symptoms, diagnosis and treatment of angina pectoris.

Table of Contents

Causes of angina pectoris

Ischemic heart disease is the most common cause of angina pectoris.
Abnormalities of aortic valves such as aortic valve stenosis, sudden arterial spasm, etc. may also cause angina pectoris.
The main reason behind all these causes is inadequate supply of oxygen to the heart or excessive demand of oxygen by heart.
Some other reasons like, extreme cold exposure, heavy meals, vivid dreams, physical exertion, intense emotion, etc. may produce angina.

Types of angina pectoris

There are different types of angina pectoris depending on their cause and symptoms.

Stable angina: It is the most common form of angina. It happens during excessive physical activity like exercise, coitus and usually goes away with rest or medications. The pain in stable angina is predictable and usually similar to previous episodes of chest pain. This chest pain last for very short duration like five minutes or less.

Unstable angina: Unstable angina is predictable and may occur at rest with less physical activity. It may last for 20 minutes or more. The pain is not relieved with rest or usual angina medication. If the blood flow does not increase, the heart is starved of oxygen and heart attack occurs. Unstable angina is dangerous and require emergency medical treatment.

Variant angina (Prinzmetal angina): Variant angina caused due to spasm in the hearts arteries that temporary reduces blood flow. Severe chest pain is the main symptom of variant angina. The episode of variant angina often occurs in cycles, typically at rest and overnight.

Refractory angina: In this type angina episodes are frequent despite use of combination of medications and lifestyle change.

Symptoms of angina pectoris

The symptoms of angina may vary depending on type, duration and severity of angina.

Chest pain or sense of tightness in the chest especially beneath the sternum (breast bone) is the most common symptom of angina.
Sometimes chest pain may radiate to throat, jaw, teeth and arms.
Feeling of heaviness or uselessness in hand is reported.
Typical anginal pain can be experienced during start of walk (start-up angina), upon laying flat (decubitus angina) or after awakening (nocturnal angina).
Above symptoms become severe upon heavy exertion, exposure to cold condition, emotional excitement or even after meal.

Diagnosis of angina pectoris

Physical examination: The primary diagnosis of angina depends on the symptoms felled by patients like, kind of pain, duration of pain, physical exertion, meal, etc.

ECG examination

Resting ECG: It is of little use and helpful to find previous myocardial infarction. In resting ECG, flattening of ‘T’ wave is seen.

Exercise ECG: In this case workload of heart is increased by exercise and ECG is recorded during exercise stress. The common findings in exercise ECG are changes in ‘ST’ segment, abnormal pumping of left ventricles.

Coronary angiography: This is the invasive test, used when other non-invasive tests have failed to detect angina. Angiography reveals the severity of disease and suggest view regarding need of angioplasty.

Radionuclide imaging: In this technique a small dose of radioactive chemical is used to scan heart muscles, it is painless. This technique confirms the presence of ischemia along with the region and number of cells affected.

Risk factors of angina pectoris

Increasing age
Family history of heart disease
High blood pressure
High cholesterol or triglycerides
Obesity
Emotional stress
Cold temperature

Treatment of angina pectoris

The main objectives of angina treatment are as follows;

Identification and removal of contributory factors
Control of risk factors
Control of clinical manifestations
Improve life expectancy

The treatment of angina pectoris is divided into three different ways; general measures, pharmacotherapy and surgical management.

General measures

It is associated with non-pharmacological practice to avoid risk factors and to reduce requirement of medicines. The common measures are reduction in fat intake, stopping consumption of tobacco products.

Pharmacotherapy

A variety of drugs are used to reduce the cardiac workload and to maintain demand and supply of oxygen to heart.

Nitrates: Eg. Nitroglycerine, isosorbide dinitrate, etc.
Antiplatelet drugs: Aspirin, clopidogrel, etc.
Calcium channel blockers: Eg. Amlodipine, diltiazem, nifedipine, etc.
Beta blockers: Atenolol, metoprolol, propranolol, etc.

Surgical management

Surgical management of angina includes percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass grafting (CABG).

Percutaneous transluminal coronary angioplasty (PTCA)

It is also known as coronary angioplasty. It is an effective symptomatic treatment for chronic stable angina. This technique involves the insertion of guidewire through peripheral artery (usually femoral artery in leg) to coronary stenosis followed by removal of stenosis (dialation). A more advanced device made up of wire mesh (stent) effectively reduce the risk and further obstruction.

Coronary artery bypass grafting (CABG)

This technique is commonly known as bypass surgery, which is highly effective in uncomplicated angina. About more than 85% of patients shows complete relief after surgery. It also improves exercise tolerance and reduces requirement of drug therapy. The surgery involves grafting of veins or arteries from aorta to coronary artery to bypass the stenosis. Low dose of aspirin (75-150mg per day), controlled exercise, low consumption of fat, etc. helps to improve graft potency and reduction in progress of angina.

Summary

Angina pectoris is a medical condition characterized by chest pain or discomfort caused by reduced blood flow to the heart muscle. It often occurs during physical exertion or stress due to narrowed coronary arteries. The pain is typically described as tightness, pressure or squeezing in the chest and may radiate to arms, neck, jaw, shoulder or back. Diagnosis involves medical history, physical examination and imaging tests. Treatment options include lifestyle changes, medications and in some cases surgical interventions, to improve blood flow to the heart. Angina pectoris is the significant indicator of underlying heart issues and requires careful management to reduce the risk of more severe cardiovascular events.