ANGINA:
Angina is characterized by paroxysmal attacks of pain in the chest due to insufficient supply of blood to the heart muscle, usually due to blockage in the coronary arteries.
Angina was first identified by William Herberden on July 21st, 1768, " of a Disorder of the Breast," to which he gave the name" Angina Pectoris," based on the study of 20 cases.
Cardiac Ischemia is the condition when there is decreased blood flow and oxygen to the heart muscle. Ischemia is associated with short term angina. It does not lead to permanent damage, but is a life threatening factor. Ischemia can lead to dysrhythmia and myocardial infarction.
ANGINA IS CAUSED BY THE IMBALANCE BETWEEN SUPPLY AND DEMAND OF OXYGEN TO THE HEART MUSCLE.
CHARACTERISTICS OF ANGINA PAIN:
Angina pain may have the following characteristics.
DIFFUSED PAIN: a crushing pain in your chest under your breastbone, it may radiate into your shoulders, arms (specially left arm), elbow, wrist, fingers, your upper back, jaw and neck.
INITIATING FACTORS: the pain may initiate by any activity which causes increased demand of oxygen by the heart muscle. such as; exercise, exposure to cold, sexual intercourse, heavy food consumption, smoking and stress.
TYPES OF ANGINA AND ANGINA PAIN:
STABLE ANGINA: this type of angina is caused by exercising, when heart consumption of oxygen is increased. it is relieved by resting, lowering blood pressure and pulse rate.
UNSTABLE ANGINA: also known as angina before heart attack. dangerous type of angina. This type of angina pain may occur while resting or sleeping in night. Severity and duration of pain is increased and may wake up patient in the middle of night. urgent diagnosis is required, pain is relieved a little by taking 5-6 sublingual tablets.
NOCTURNAL ANGINA: it occurs during the REM phase of sleep while dreaming. At night, the venous return to the heart increases due to the supine position. This increase in venous return has increased the left ventricular diameter. As a result, diastolic end pressure and diastolic end volume increase. As a result, the elasticity of myocardial fibers increases. This increase in traction increases myocardial oxygen consumption and pain appears. this pain is relieved by reducing the diameter of left ventricle, therefore digoxin is the drug of choice.
ANGINA PECTORIS: pain occurs when bending or lying down. The cause of this type of angina is increased venous return to the heart. this relieves shortly after sitting or standing.
PRINZMETAL ANGINA/VARIANT ANGINA: it always occurs when a person is at rest, usually between midnight and early morning. These attacks can be very painful. The pain from variant angina is caused by a spasm in the coronary arteries, which supply blood to the heart muscle. the pain can be relieved by taking medication, and the drug of choice are nitrates and calcium channel blockers.
FACTORS CONTRIBUTING TO ISCHEMIA AND ANGINA:
SYSTEMATIC FATORS:
Myocardial supply demand ratio.
pulse rate
blood pressure
heightened systemic activation
CARDIAC FACTORS:
heart failure
left ventricular hypertrophy
diastolic dysfunction
valvular heart disease
left ventricular outflow tract obstruction
CORONARY FACTORS:
obstructive CAD
microvascular dysfunction
coronary artery spasm
myocardial bridging
endothelial dysfunction
SIGN AND SYMPTOMS:
Dyspnea
tachycardia
palpitations
nausea
vomiting
fatigue
sweating
paleness
weakness
syncope
One of the ablest students described his own fatal attack in this way:
"Anginal attacks with very severe pains. Pulse in the attack very variable, at one time slow, 56 to 60, quite regular, high tension, and then again rapid, 80 to 90, tolerably even and regular, then again quite unrhythmic, unequal at one time, rapid another, slow with changed tension. The first sensation of this attack dates three or four years back, at first slight, gradually becoming more pronounced. Very severe attacks with great pain have only come on within he last five or six days. written after three severe attacks".
RISK FACTORS FOR ANGINA:
AGE: As the age increases, plaque can build up in the arteries.
ENVIRONMENT: Angina may be linked to air pollution or your work life can increase the risk of angina.
GENETICS: Angina may run in your family history.
LIFESTYLE: Alcohol, smoking, illegal medicine use, lack of physical activity are associated risks of angina.
MEDICAL CONDITIONS: Anemia, cardiomyopathy, inflammation, high blood pressure increase the risk.
SEX: Women may have increased risk of angina around the time of menopause.
TREATMENT:
Approaches to treat angina:
increasing blood flow towards heart.
lowering hearts workload.
Treatment is based on the type of angina, symptoms and lab reports.
beta blockers: help your heart beat with less force. Avoid beta blockers if you have vasospastic angina.
nitrates: widen and relax your blood vessels.
calcium channel blockers: relax the muscles of heart and blood vessels.
FOR PREVENTION OF HEART ATTACK:
antiplatelet medicines: keep blood clot from forming.
anticoagulant medicines: lower risk of blood clotting.
statins: stops plaque from forming and slow down coronary heart disease.
REFERENCES:
Osler W. The Lumleian lectures on angina pectoris. The Lancet. 1910 Mar 12;175(4515):697-702.
Hassan MA. Angina Pectoris. Eurasian Journal of Chemical, Medicinal and Petroleum Research. 2023 Aug 19;2(5):212-20.
Baijia Li, Yajuan Fan, Binbin Zhao, Lihong Yang, Jian Yang, Xiancang Ma, Bin Yan, Later bedtime is associated with angina pectoris in middle-aged and older adults: results from the Sleep Heart Health Study, Sleep Medicine, Volume 79, 2021, Pages 1-5, ISSN 1389-9457, https://doi.org/10.1016/j.sleep.2020.12.035.
Ford TJ, Berry C. Angina: contemporary diagnosis and management. Heart. 2020 Mar 1;106(5):387-98.
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