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==Overview== | ==Overview== | ||
'''Angina pectoris''', commonly known as '''angina''', is [[chest pain]]<ref name="urlMerckMedicus : Dorlands Medical Dictionary">{{cite web |url=http://merckmedicus.com/pp/us/hcp/thcp_dorlands_content_split.jsp?pg=/ppdocs/us/common/dorlands/drlnd/one_04/000004934.htm#000004934 |title=MerckMedicus : Dorland's Medical Dictionary |format= |work= |accessdate=2009-01-09}}</ref> due to [[ischemia]] (a lack of blood and hence [[oxygen]] supply) of the [[myocardium|heart muscle]], generally due to obstruction or spasm of the [[coronary circulation|coronary arteries]] (the heart's blood vessels). [[Coronary heart disease|Coronary artery disease]], the main cause of angina, is due to [[atherosclerosis]] of the cardiac arteries. The term derives from the [[Greek language|Greek]] ''ankhon'' ("strangling") and the [[Latin]] ''pectus'' ("chest"), and can therefore be translated as "a strangling feeling in the chest". In [[angina pectoris]] the sensation of [[chest discomfort]] can be a feeling of tightness, heaviness, or pain. | '''Angina pectoris''', commonly known as '''angina''' or '''chronic stable angina''', is [[chest pain]]<ref name="urlMerckMedicus : Dorlands Medical Dictionary">{{cite web |url=http://merckmedicus.com/pp/us/hcp/thcp_dorlands_content_split.jsp?pg=/ppdocs/us/common/dorlands/drlnd/one_04/000004934.htm#000004934 |title=MerckMedicus : Dorland's Medical Dictionary |format= |work= |accessdate=2009-01-09}}</ref> due to [[ischemia]] (a lack of blood and hence [[oxygen]] supply) of the [[myocardium|heart muscle]], generally due to obstruction or spasm of the [[coronary circulation|coronary arteries]] (the heart's blood vessels). [[Coronary heart disease|Coronary artery disease]], the main cause of angina, is due to [[atherosclerosis]] of the cardiac arteries. The term derives from the [[Greek language|Greek]] ''ankhon'' ("strangling") and the [[Latin]] ''pectus'' ("chest"), and can therefore be translated as "a strangling feeling in the chest". In [[angina pectoris]] the sensation of [[chest discomfort]] can be a feeling of tightness, heaviness, or pain. | ||
Angina pectoris is a sign of [[coronary heart disease]]. If it occurs chronically this is called [[stable angina]]. If it occurs at rest or in an accelerating pattern this is called an [[acute coronary syndrome]] and can be a symptom of either: | Angina pectoris is a sign of [[coronary heart disease]]. If it occurs chronically this is called [[stable angina]]. If it occurs at rest or in an accelerating pattern this is called an [[acute coronary syndrome]] and can be a symptom of either: | ||
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Overview
Angina pectoris, commonly known as angina or chronic stable angina, is chest pain[1] due to ischemia (a lack of blood and hence 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 Greek ankhon ("strangling") and the Latin pectus ("chest"), and can therefore be translated as "a strangling feeling in the chest". In angina pectoris the sensation of chest discomfort can be a feeling of tightness, heaviness, or pain.
Angina pectoris is a sign of coronary heart disease. If it occurs chronically this is called stable angina. If it occurs at rest or in an accelerating pattern this is called an acute coronary syndrome and can be a symptom of either:
- Unstable angina: An open artery with insufficient blood flow to the heart but without irreversible damage
- Non ST elevation MI: An open artery with insufficient blood flow to the heart with irreversible damage
- ST elevation MI: A closed artery with insufficient blood flow to the heart and irreversible damage
Pathophysiology
Whenever there is limitation in the flow through one or more coronary arteries, there occurs a mismatch between the oxygen supply and demand to the myocardium. This activates the molecular cascade and release of bradykinin, adenosine which stimulate the sympathetic and vagal afferent fibers, causing the anginal pain. Certain conditions can increase the myocardial oxygen demand secondary to increase cardiac output(like fever, thyrotoxicosis, stress, tachyarrythmias)
Clinical presentation
Most of the patients will present with pain or discomfort which may be typical, but commonly is atypical. Some patients also present with dyspnea instead of pain and this is termed as angina equivalent. History is extremely helpful and should include an assessment of risk factors as well. Physical examination may be normal or reveal findings of heart failure. Other findings to look for are peripheral vascular disease which is considered to be risk factor for CAD.
Calculating pretest probability for CAD
Pretest probability tells the probability of a target disorder before the result of the diagnostic test(s) are known. In case of angina, initial history and physical examination can help categorize the patient into low, intermediate or high probability group. This will then help in deciding the type of testing, interpreting result of the test and timing for starting the treatment.
Diagnostic tests
This includes lab tests like lipid profile, hemoglobin and hematocrit, blood glucose, TSH. ECG should be done but one shuld remember that it may be normal in majority of cases. Some findings to look for are evidence of active ischemia like ST-T wave depression, left ventricular hypertrophy, Q waves in multiple leads suggestive of old MI, bundle branch blocks, arrythmias. These findings will also help in choosing the next diagnostic test. Chest X-ray may be normal or show cardiomegaly or pulmonary vascular congestion. Specific cardiac tests for angina include exercise ECG testing, myocardial perfusion imaging, echocardiography, stress echocardiography and coronary angiography. Choice of these tests is based largely on initial history and physical examination as well as resting ECG findings.
Treatment
Treatment for chronic stable angina includes lifestyle modification, pharmacotherapy and revascularization procedures(PCI, CABG). It is also important to identify any exacerbating factors like anemia, thyrotoxicosis, valvular heart disease or decompensated heart failure and treat them first, when possible. Smoking cessation counselling, diet and weight management, promoting physical exercise, BP and diabetes control are all part of risk factor modification and should be stressed at each clinic visit. Specific medical therapy includes antiplatelets(like ASA, clopidogrel), antianginals(like nitrates, beta blockers, calcium channel blockers, antilipid agents, ACE inhibitors and angiotensin receptor blocking agents. Coronary revascularization is recommended when optimal medical therapy has failed to reduce symptoms or severe atherosclerotic disease or high risk criteria on noninvasive testing. Options available for revascularization are Percutaneous coronary interventionPCI and coronary artery bypass graftingCABG. In patients with chronic stable angina, the factors influencing the choice of coronary revascularization therapy (percutaneous coronary intervention or coronary artery bypass surgery) are varied and complex. The severity of symptoms, lifestyle, extent of objective ischemia, and underlying risks must be weighed against the benefits of revascularization and the patient’s preference, as well as local availability and expertise. Evidence from randomized trials and large revascularization registers can guide these decisions, but the past decade has seen rapid change in medical treatment, bypass surgery and percutaneous coronary intervention.
Prognosis and risk stratification
Ischemic heart disease remains number one cause of mortality in developed countries. Prognosis of stable angina varies widely depending on severity of symptoms, extent of atherosclerosis and presence of other risk factors and co-morbidities. For this reason, it is important to risk stratify every patient. This can be done with the help of history, physical exam and use of one or more of diagnostic tests like ECG, Echocardiography, exercise ECG testing, myocaridal perfusion imaging or coronary angiography.
References
- ↑ "MerckMedicus : Dorland's Medical Dictionary". Retrieved 2009-01-09.