Angina


ANGINA

Description:

Angina is chest pain or discomfort that occurs when an area of your heart muscle does not get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. It can feel like indigestion. Angina itself is not a disease, rather, it's a symptom of an underlying heart problem. Angina is usually a symptom of coronary artery disease (CAD), the most common type of heart disease.

CAD occurs when a fatty material called plaque builds up on the inner walls of the coronary arteries. These arteries carry oxygen-rich blood to your heart. When plaque builds up in the arteries, the condition is called atherosclerosis. Paque causes the coronary arteries to become narrow and stiff. The flow of oxygen-rich blood to the heart muscle is reduced. This causes pain and can lead to a heart attack.

Types of Angina: The three types of angina stable, unstable, and variant (Prinzmetal's). They have different symptoms and require different treatment.

1. Stable Angina: Stable angina is the most common type. It occurs when the heart is working harder than usual. Stable angina has a regular pattern. If you know you have stable angina, you can learn to recognize the pattern and predict when the pain will occur. The pain usually goes away in a few minutes after you rest or take your angina medicine. Stable angina isn't a heart attack, but it makes a heart attack more likely in the future.

Unstable Angina: Unstable angina does not follow a pattern. It can occur with or without physical exertion and is not relieved by rest or medicine. Unstable angina is very dangerous and needs emergency treatment. It's a sign that a heart attack may happen soon.

Angina

Variant (Prinzmetal's) Angina: Variant angina is rare. It usually occurs while you are at rest. The pain can be severe. It usually happens between midnight and early morning. This type of angina is relieved by medicine.

Symptoms:

Pain and discomfort are the main symptoms of angina. Angina is often described as pressure, squeezing, burning, or tightness in the chest. It usually starts in the chest behind the breastbone. Pain from angina also can occur in the arms, shoulders, neck, jaw, throat, or back. It may feel like indigestion. Some people say that angina discomfort is hard to describe or that they can't tell exactly where the pain is coming from. Symptoms such as nausea (feeling sick to your stomach), fatigue (tiredness), shortness of breath, sweating, light-headedness, or weakness also may occur. Women are more likely to feel discomfort in their back, shoulders, and abdomen.

Treatment:

When angina is caused by coronary artery disease, treatment usually includes:

Lifestyle Changes: Changes include weight loss for obese patients, therapy to quit smoking, medications to lower high cholesterol, a program of regular exercise to lower high blood pressure, and stress reduction techniques (for example, meditation and biofeedback).

Nitrates: Medications that widen blood vessels (vasodilators). They increase blood flow in the coronary arteries, and make it easier for the heart to pump blood to the rest of the body.

Beta-blockers: Atenolol (Tenormin) and metoprolol (Lopressor, Toprol-XL). These medications decrease the heart's workload by slowing the heart rate and reducing the force of the heart's contractions, especially during exercise.

Calcium channel blockers: Nifedipine (Adalat, Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem (Cardizem, Tiazac), amlodipine (Norvasc) These medications may help to improve the efficiency of heart-muscle function and may decrease the number and severity of chest pain episodes.

Aspirin helps to prevent blood clots from forming inside narrowed coronary arteries; it can reduce the risk of heart attacks in people who already have coronary artery disease.

If lifestyle changes and drugs fail to ease angina or when the risk of heart attack is great, your doctor may recommend balloon angioplasty or coronary artery bypass surgery.

Medical Procedures: When medicines and other treatments don't control angina, you may need a medical procedure to treat the underlying heart disease. Angioplasty and coronary artery bypass grafting (CABG) are both commonly used to treat angina.

Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores blood flow.

Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure.

During CABG, healthy arteries or veins taken from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. Bypass surgery can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.

Your doctor will help decide which treatment is right for you.

Cardiac Rehabilitation

Your doctor may prescribe cardiac rehab for angina or after angioplasty, CABG, or a heart attack.

The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.

Rehab has two parts:

Exercise training: This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests.

Education, counseling, and training: This part of rehab helps you understand your heart condition and find ways to reduce your risk of future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and to deal with your fears about the future.

Causes and Risk factors:

Damage to the inner layers of coronary arteries due to smoking, high levels of fat and cholesterol in the blood, hypertension and high sugar levels in the blood can cause CAD. It is known now that angina is a symptom of Coronary Artery Disease (CAD) leading to reduced oxygenated blood flow to the myocardial muscle. The human body has a built in mechanism of healing the damaged portion with the help of excess fatty tissues that release compounds that promote the healing process. Thus, it is clear that healing leads to building up of plaque at points of arterial damage causing the arteries to narrow. Plaque may narrow the arteries or even block the arteries hindering the blood flow to myocardial muscle.

Causes for Stable Angina:

1. Physical exertion

2. Emotional stress

3. Exposure to extreme hot or cold temperatures

4. Heavy meals

5. Smoking

Causes for Unstable Angina:

Plaque (built up) in an artery ruptures or breaks open leading to blood clots that block an artery partially or totally causing unstable angina.

Causes of Variant Angina:

1. Exposure to cold

2. Emotional stress

3. Smoking

4. Use of Cocaine

5. Medications that narrow blood vessels (1)

Other general causes of angina are:

1. Congenital/structural anomalies of coronary arteries

2. Reduced oxygen carrying capacity of blood such as severe anemia or increased carboxyhemoglobin.

3. Compression or squeezing of coronary arteries

4. Inflammation or infection of coronary arteries

5. Severe Aortic stenosis i.e., heart valve disease leading to narrowing of outflow of blood from heart

6. Hypertrophy or thickening of heart muscle leading to hypertension (4), (5) & (7)

Risks

The following risk factors contribute to Angina:

1. Coronary calcification

2. Usage of tobacco

3. Elevated C-Reactive Protein

4. Elevated Low Density Lipoprotein (LDL) or cholesterol

5. Diabetes Mellitus

6. Inherited ischemic disease

7. Obesity

8. Sedentary life style or least physical activity (9)

Diagnosis:

Angina is usually a warning sign of the presence of significant coronary artery disease. Patients with angina are at risk of developing a heart attack (myocardial infarction). A heart attack is the death of heart muscle precipitated by the complete blockage of a diseased coronary artery by a blood clot.

During angina, the lack of oxygen (ischemia) to the heart muscle is temporary and reversible. The lack of oxygen to the heart muscle resolves and the chest pain disappears when the patient rests. In contrast, the muscle damage in a heart attack is permanent. The dead muscle turns into scar tissue when healed. A scarred heart cannot pump blood as efficiently as a normal heart, and can lead to heart failure.

Up to 25% of patients with significant coronary artery disease have no symptoms at all, even though they clearly lack adequate blood and oxygen supply to the heart muscle. These patients have "silent" angina. They have the same risk of heart attack as those with symptoms of angina.

Diagnostic Tests and Procedures

EKG (Electrocardiogram): An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. However, some people with angina have a normal EKG.

Stress Testing: During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. During exercise stress testing, your blood pressure and EKG readings are checked while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time.

If you're unable to exercise, a medicine can be injected into your bloodstream to make your heart work hard and beat fast. Nuclear heart scanning or echocardiography is then usually done.

When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs.

Chest X-ray: A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Coronary Angiography and Cardiac Catheterization: Your doctor may ask you to have coronary angiography if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through the coronary arteries.

Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

Blood Tests: Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD.

Your doctor may order a blood test to check the level of C-reactive protein (CRP) in your blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CAD and heart attack.

Medicine and medications:

Aspirin: Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clotting may reduce your risk of a heart attack.

Nitrates: Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle. You might take a nitrate when you have angina-related chest discomfort, before doing something that usually triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is with nitroglycerin tablets that you put under your tongue.

Beta blockers: Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, your heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina.

Statins: Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in the buildup of fats (plaques) in your artery walls, helping prevent further blockage in your blood vessels.

Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina. Calcium channel blockers also slow your pulse and reduce the workload on your heart.

Angiotensin-converting enzyme (ACE) inhibitors: These drugs help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system in numerous ways, including narrowing your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder.

Ranolazine (Ranexa): This drug is used only when other anti-angina drugs haven't worked because it can cause a heart problem known as QT prolongation, which increases your risk of heart rhythm problems. It's used with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.

If you try drug treatment and lifestyle changes and you still have symptoms that are limiting you, a stent may be the next step.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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