ANGINA PECTORIS

Angina pectoris is a symptom complex of IHD characterized by paroxysmal and usually recurrent attacks of
substernal or precordial chest discomfort (variously described as constricting, squeezing, choking, or knifelike)
caused by transient (15 seconds to 15 minutes) myocardial ischemia that falls short of inducing the cellular necrosis
that defines infarction.
Chest pain resulting from an imbalance between oxygen supply and demand, and is most commonly caused by the
inability of atherosclerotic coronary arteries to perfuse the heart under conditions of increased myocardial oxygen
consumption.
Classification of Angina Pectoris
Stable Angina: The most common anginal syndrome.
o Description of the pain:
Character: More often described as a discomfort, pressure, or squeezing sensation. Less commonly as burning,
sticking, or sharp. May feel like gas or indigestion.
Location: Most often in the substernal area, precardium, or epigastrium with radiation to the left arm, jaw, or
neck. Less commonly felt only in radiation areas and not in the chest.
Precipitation: Often provoked by exertion, emotion, exposure to cold, eating (4 "E"s), or smoking, and relieved by
rest, removal of provoking factors, or sublingual nitrates.
Duration: Usually lasts a few minutes, rarely over 20-30 minutes.
Unstable Angina Pectoris (Crescendo Angina)
Unstable angina causes unexpected chest pain, and usually occurs while resting. The most common cause is
reduced blood flow to the heart muscle because the coronary arteries are narrowed by fatty buildups
(atherosclerosis) which can rupture causing injury to the coronary blood vessel resulting in blood clotting which
blocks the flow of blood to the heart muscle. Blood clots that block an artery partially or totally are what causes
unstable angina. Inflammation, infection and secondary causes can also lead to unstable angina.
Unstable angina pectoris usually presents in one of three patterns:
o angina pectoris of recent onset (less than 1 month) that is provoked by minimal exertion.
o chronic stable angina showing a crescendo pattern, with chest pain occurring more frequently, with
greater severity and duration, with less provocation, and requiring larger doses of nitroglycerine to abort
attacks.
o prolonged chest pain at rest.

Variant Angina Pectoris (Prinzmetal's Angina)
This type of angina results from transmural myocardial ischemia caused by coronary artery spasm and may occur
in patients with or without coronary atherosclerosis. Pain occurs principally at rest. Although individuals with this
form of angina may well have significant coronary atherosclerosis, the anginal attacks are unrelated to physical
activity, heart rate, or blood. The pain may occur in a circadian manner, often at night or in the early morning
hours. The pain is associated with ST-segment elevation, in contrast to typical angina pectoris. Prinzmetal angina
generally responds promptly to vasodilators, such as nitroglycerin and calcium channel blockers.

Evaluation
History
The diagnosis of angina pectoris is established by obtaining a reliable description of the chest discomfort and its
relationship to activity. The likelihood of coronary artery disease is enhanced by age, history of hypertension,
hyperlipidemia, smoking, diabetes mellitus, or a family history of ischemic heart disease in first degree relatives.
Physical Examination
Though often normal, the physical examination may supply important information that will affect evaluation: the
appearance of the patient, especially in an episode of pain; xanthelasmia; hypertension; evidence of peripheral
arterial disease; tenderness of the chest wall suggesting pain of musculoskeletal origin; abnormal pulsations on
palpation over precardium; basilar rales; an S4, especially during pain; murmurs of aortic stenosis, IHSS, mitral valve
prolapse; or arrhythmias.
Blood Test
Basic screening for anemia, polycythemia, hyperglycemia, hyperlipidemia, etc.
Resting ECG
A resting ECG is often normal in stable angina pectoris in the absence of a previous MI or a cause for LVH. During
pain the ECG may show transient ST- segment depression, T wave inversion, and/or ventricular arrhythmia.
Abnormal ECG changes are more common with unstable angina pectoris. ST-segment elevation rather than
depression occurs during attack in variant angina.
Echocardiography
Especially with 2D echocardiography, the assessment of left ventricular wall motion, volume, and ejection fraction
is feasible, as is detection of IHSS, AS, and LVH.
Exercise Stress Testing
Most, but not all, physically able patients with stable angina pectoris should have an exercise stress test as it is very
helpful in reproducing symptoms, documenting ischemic ECG changes, and assessing the level of severity. Patients
with high grade coronary artery disease may manifest inability to elevate the heart rate or blood pressure during
exercise, or develop marked ST-changes at low level exercise. The exercise stress test may be combined with
echocardiography (Echo Stress Test) for more specificity. This is particularly useful in females, as they tend to have
a higher rate of false positive tests.
Ambulatory Holter Monitoring
Ambulatory monitoring with equipment designed to show ST-T changes is useful in some cases and is especially
good for detecting silent ischemia.
Radioisotope Studies
Radionuclide scintigraphy enhances the sensitivity and specificity of the exercise stress test. The patient with a
normal ECG at rest may require only a standard exercise test. If abnormal at rest, such as ST-T abnormalities or
LBBB, etc., the patient is best evaluated with Thalium scintigraphy performed during the exercise stress test.
Nuclear ventriculogram using tecnetium Tc 99 m tagged to the patient's RBCs permits evaluation of left ventricular
wall motion and measurement of ejection fraction.
Coronary Arteriography
Although not necessary for the diagnosis of coronary artery disease in most instances, cardiac catheterization and
coronary angiography is the "court of last resort" for evaluating patients with chest pain. It is the only currently
available diagnostic test that depicts coronary anatomy and defines the extent of the coronary artery disease. It is
a necessary procedure for all patients who are potential surgical candidates. Some of the usual indications for
coronary arteriography in angina pectoris include:
o angina refractory to medical management.
o unstable angina (after medical stabilization).
o marked ST-T changes at low level or persisting after cessation of exercise stress testing.
o angina or myocardial infarction in patients under 35 years of age.
o patients with persistent angina and/or low level EST abnormalities after myocardial infarction.
o suspected variant (Prinzmetal's) angina.
o when needed for clarification of an obscure case.
Management
Stable Angina Pectoris
o General Therapeutic Considerations (Table 1)
o Drug Therapy
Table 1. General Therapeutic Considerations
Risk factor reduction: Discontinue smoking, control hypertension
and diabetes, lower hyperlipidemia, and maintain an ideal body weight.
Work adjustment, stress reduction, and behavioral modification.
Exercise: The prescription for exercise must be made carefully with the
knowledge of each individual patient taken into consideration.
The drugs most frequently used in the treatment of stable angina pectoris are the nitrates, the beta blockers, and
the calcium channel blockers.
For routine patients with no other problems, a good regimen would be a nitrate and a beta blocker. For patients
with asthma, CHF, or insulin-dependent diabetes mellitus, the beta-blockers are relatively contraindicated and a
calcium channel blocker should be employed. Some physicians prefer to start the patient on calcium channel
blockers as initial therapy. Some patients may require all three medications, and occasionally combinations of
calcium channel blockers are used.
o Percutaneous Transluminal Coronary Angioplasty (PTCA)
Transluminal coronary angioplasty has become an accepted method of treating selected patients with angina due
to atheromatous coronary artery disease. This procedure is particularly useful in patients with single or double
vessel disease, especially for lesions of the left anterior descending coronary artery.
o Coronary Artery Bypass Grafting (CABG)
Coronary artery bypass grafting can provide significant relief from angina in over 80% of patients with disabling
angina and has a low operative mortality. Its use is limited to those patients who cannot be managed medically,
those with markedly abnormal ECG response to exercise, and those found to have significant left main coronary
steno-sis or significant proximal lesions in all three coronary arteries.
Unstable Angina Pectoris
Hospitalization with bed rest, nasal O2, and sedation in an ECG-monitored environment is indicated for almost all
patients with unstable angina. Most patients with unstable angina will respond to medical management and can
then be evaluated for extent of severity with the diagnostic tests used for stable angina. More than 30% to 40% of
medically treated patients will have PTCA or CABG surgery.
Variant Angina Pectoris
o Drugs (Table 2)
Table 2. Drugs
Nitrate Sublingual nitrates usually reverse spasm within 30-60 seconds. Oral or tropical
nitrates can reduce the frequency of attacks. However, nitrates are not always
successful, and abrupt withdrawal can provoke spasm. so it is important to taper
off regardless of their seeming ineffectiveness.
Calcuim Channel Blockers Effective in 60%-75% of patients, with or without nitrates.
Beta Blockers Beta Blockers are ususally ineffective and may actually be deleterious in variant angina.
o PTCA/Coronary Bypass Surgery
Variant angina is usually not amenable to PTCA or CABG surgery except in select cases with fixed subtotal
obstructions which are the site of reproducible superimposed spasm.