ANGINA PECTORIS 

Angina pectoris is a clinical syndrome usually characterized by episodes of paroxysms of pain or pressure in the anterior chest. The cause is usually insufficient coronary blood flow. The insufficient flow results in a decreased oxygen supply to meet increased myocardial demand for oxygen in response to physical exertion or emotional stress.

Angina is categorized by:-

• Stable-In stable angina, symptoms are consistent and pain is relieved by rest.
• Unstable-In unstable angina, pain is marked by increasing severity, duration, and frequency. Pain from unstable angina responds slowly to nitroglycerin and isn’t relieved by rest.
• Prinzmetal’s (variant)-pain is unpredictable and may occur at rest.

Pathophysiology 
Angina is usually caused by atherosclerotic disease. Almost invariably, angina is associated with a significant obstruction of a major coronary artery.

CAUSES 

• Activity or disease that increases metabolic demands
• Aortic stenosis
• Atherosclerosis
• Pulmonary stenosis
• Stress or any emotion-provoking situation, causing the release of adrenaline and increasing blood pressure, which may accelerate the heart rate and increase the myocardial workload.
• Exposure to cold, which can cause vasoconstriction and elevated blood pressure, with increased oxygen demand.
• Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle.
• Thromboembolism
• Vasospasm

Clinical Manifestations 

• Pain varies from a feeling of indigestion to a choking or heavy sensation in the upper chest ranging from discomfort to agonizing pain.
• The patient with diabetes mellitus may not experience severe pain with angina.
• A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting, may accompany the pain.
• The pain is usually retrosternal, deep in the chest behind the upper or middle third of the sternum.
• Angina is accompanied by severe apprehension and a feeling of impending death.
• Discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspect of the upper arms (usually the left arm).
• Anxiety may occur with angina.

Assessment

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Diagnostic Methods 

Evaluation of clinical manifestations of pain and patient history.

Electrocardiogram changes (12-lead ECG), stress testing, blood tests.

Echocardiogram, nuclear scan, or invasive procedures such as cardiac catheterization and coronary angiography.

ECG shows ST-segment depression and T-wave inversion during anginal pain.

TREATMENT

Pharmacologic therapy 

• Antiplatelet and anticoagulant medications (aspirin, clopidogrel, heparin, glycoprotein [GP] IIb/IIIa agents [abciximab, tirofiban, eptifibatide])
• Beta-adrenergic blockers: propranolol (Inderal), nadolol (Corgard), atenolol (Tenormin), metoprolol (Lopressor)
• Calcium channel blockers: verapamil (Calan), diltiazem (Cardizem), nifedipine (Procardia), nicardipine (Cardene)
• Low-dose aspirin therapy
• Nitrates: nitroglycerin, isosorbide dinitrate (Isordil), topical nitroglycerin, transdermal nitroglycerin (Transderm-Nitro)
• Oxygen therapy
• Diet: low fat, low sodium, and low cholesterol (low calorie if necessary)
• Coronary artery bypass grafting

• Percutaneous Transluminal Coronary Angioplasty (PTCA) and intracoronary stenting. It is often performed electively in patients who continue to have symptoms of angina despite medication. PCI may also be performed urgently as a treatment option for patients presenting with ST-elevation myocardial infarction (STEMI). PTCA involves widening a coronary artery from within using a balloon catheter in an attempt to increase the blood supply to the myocardium. The catheter is inserted into the artery (femoral, radial or less commonly brachial) and guided through the arterial system under X-ray guidance. Contrast medium is injected into the coronary artery to determine the size and location of the atherosclerotic plaque(s). The balloon is then advanced and inflated to compress the plaque against the arterial wall, resulting in the widening of the coronary artery.
• Stent placement
• Semi-Fowler’s position

Assessment of Angina

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