Angina Pectoris
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Contents |
Introduction
- Commonly, referenced as angina.
Etiology
-
- aortic stenosis
- hypertrophic cardiomyopathy
- pharmaceutical causes: ( exacerbation)
Epidemiology
- 5-7% of population from 44 to 75 years of age
- risk increases with age
Pathology
- myocardial ischemia secondary to reduced blood flow through partially obstructed coronary arteries
Clinical-manifestations
- steady precordial pressure or pain
- induced by exercise, emotion, or eating
- radiation to the jaw or left shoulder & arm
- duration of pain < 20 minutes
- dyspnea, especially female, diabetic, elderly
- diaphoresis
- fear of death
- nausea
- relief by nitroglycerin or rest
- palpable precordial apical bulge that disappears with pain
- signs of congestive heart failure ( CHF) may be present
- 4th heart sound
- mitral regurgitant murmur secondary to papillary muscle dysfunction
Laboratory
Diagnostic-procedures
- electrocardiogram ( ECG):
- ST segment depression during pain
- T wave changes ( inversion) during pain
- Q waves suggest prior MI
- previous MI, or Q waves on ECG
- heart failure
- exercise treadmill
- able to exercise
- exercise echocardiography
- pre-excitation ( WPW)
- LBBB
- ST segment depression > 1 mm
- previous revascularization
- LV dysfunction
- NYHA class 3 or class 4 angina, despite therapy
- positive stress test
- high probability of left main coronary artery or 3-vessel disease
- uncertain diagnosis after stress test
- survivors of sudden cardiac death
- suspected coronary vasospasm ( Prinzmetal's angina)
Radiology
- graded exercise test with or without thallium or sestamibi scintigraphy
- dipyridamole thallium test or dobutamine echocardiogrphy
- severe arthritis
- morbid obesity
- stroke
- peripheral arterial disease
- pacemaker: electronically paced ventricular rhythm
- CT angiography may useful in emergency department setting
- multidetector CT shows promise [5]
Complications
- women with angina pectoris, but mild or no obstruction on angiography, are not clear of cardiovascular risk [6]
Differential-diagnosis
- see chest pain
Management
- risk factor modification
- smoking cessation reduces risk of coronary artery disease by 50% within 5 years of quitting
- aerobic exercise
- weight loss: maintenance of ideal body weight reduces risk of coronary artery disease
- control of hypertension
- control of diabetes
- dietary intervention
- reduction in calories
- reduction in total & saturated fat
- reduction in cholesterol
- reduction in sodium may be appropriate
- antioxidants have been suggested to have benefit
- Mediterranean diet, DASH diet
- pharmaceutical agents
-
- decrease heart rate & myocardial contractility achieve heart rate of 55-60/min
- useful in exercise-induced angina
- cardioselective beta blockers are preferred agents
- asthma
- symptomatic bradycardia
- heart failure
- severe peripheral arterial disease
- 75 to 325 mg QD
- effective in secondary prevention of coronary artery disease in patients with angina
- reduce preload & afterload
- dilate coronary arteries
- daily nitrate free interval of 8-10 hours
- may cause headaches
- sublingual nitroglycerin
- isosorbide (long-acting)
- transdermal nitrates
- beta-blocker cannot be used or is not sufficient to relieve symptoms
- increase coronary artery perfusion
- diminish afterload
- diltiazem or verapamil suggested [1]
- do not use short-acting calcium channel blocker ( nifedipine ..) [1]
- ACE inhibitor [1]
- LV ejection fraction < 35%
- stroke, CAD or peripheral artery disease
- diabetes & additional cardiac risk factors
- ranolazine if other options exhausted [1]
- refractory angina pectoris
- enhanced external counterpulsation
- spinal cord stimulation of the region that receives cardiac nerve fibers diminishes angina & improves functional status [1]
- routine screening in asymptomatic patients not indicated [1]
More General Terms
Additional Terms
- Prinzmetal's angina; variant angina; coronary vasospasm
- unstable angina (acute coronary syndrome, ACS)
References
- Medical Knowledge Self Assessment Program (MKSAP) 14, 15 American College of Physicians, Philadelphia 2006, 2009
- Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 227-28
- Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 85
- Hoffmann U et al, Coronary multidetector computed tomography in the assessment of patients with acute chest pain, Circulation 2006, 114:2251 PMID: [1]
- Gulati M et al, Adverse Cardiovascular Outcomes in Women With Nonobstructive Coronary Artery Disease Arch Intern Med. 2009;169(9):843-850. <PubMed> PMID: [2] <Internet> [3]
- Angina: NIH Institute and Center Resources [4]
- National Guideline Clearinghouse Angina pectoris ngc-guideline: [5]
- ACR Appropriateness Criteria for acute chest pain - low probability of coronary artery disease. ngc-guideline: [6]
- ACR Appropriateness Criteria for chest pain, suggestive of acute coronary syndrome. ngc-guideline: [7]
- Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). (ICSI) ngc-guideline: [8]
- Management of stable angina. A national clinical guideline. Scottish Intercollegiate Guidelines Network ngc-guideline: [9]
- Management of stable angina. A national clinical guideline. National Clinical Guideline Centre ngc-guideline: [10]
