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Angina pectoris occurs more frequently in men than in women, and in older persons than in younger persons. It is not a disease entity but a symptom of an underlying disease process involving the arteries that supply blood to the heart muscle. About 90 per cent of all cases can be attributed to coronary atherosclerosis. Studies have shown that at least one of the three major coronary arteries usually is stenosed before angina develops. In most cases, all of the major coronary arteries are involved.
Angina pectoris also can result from stenosis of the aorta, pulmonary stenosis and ventricular hypertrophy, or connective tissue disorders such as systemic lupus erythematosus and periarteritis nodosa that affect the smaller coronary arteries.
Coronary arteriography and ventriculography are valuable in determining the prognosis for angina pectoris. The mortality rate for patients having a narrowing of all three main coronary arteries is higher than for those who have only one vessel involved. Severity of pain is not a good prognostic indicator; some patients with severe discomfort live for many years, while others with mild symptoms die suddenly. An enlarged heart, a third heart sound, ECG abnormalities at rest, and hypertension are all indicative of a poor prognosis.
Organic nitrates may be administered orally or sublingually for relief from anginal pain. They act by dilating the arteries and may be used to treat acute attacks, for long-term prophylaxis and management, or for prophylaxis in situations likely to provoke an attack. Commonly used nitrates are erythrityl tetranitrate, isosorbide dinitrate, and nitroglycerin.
Beta-adrenergic blocking agents, such as propranolol, are used to treat patients who do not respond to weight control and treatment with vasodilators and whose angina significantly limits their activities. These agents decrease the heart rate, blood pressure, and myocardial oxygen consumption and increase the patient's exercise tolerance.
The calcium channel blocking agents (nifedipine, verapamil, diltiazem, and others) are drugs that are particularly beneficial in relieving pain in patients whose angina is the result of coronary artery spasm or constriction. They act by selectively inhibiting the transport of calcium across the cell membrane of myocardial cells and also by reducing myocardial oxygen utilization. Patients most likely to obtain dramatic relief from drugs of this kind are those who experience chest pain while resting or sleeping, upon exposure to cold, or during emotional stress.
Surgical procedures involving arterial bypass and angioplasty have become fairly common as a form of treatment of certain types of ischemic heart disease and resulting angina pectoris. The surgical procedures attempt to bypass the diseased portion of the coronary artery by suturing a vein graft or the internal mammary artery from the aorta to one or more coronary arteries beyond the area of obstruction. In most instances the graft is obtained from the patient's saphenous vein. Angioplasty reestablishes patency of the vessels; in most cases, it is now accompanied by insertion of a stent to help prevent restenosis.
An attitude of calmness and efficiency is most important when caring for a person suffering from an attack of angina pectoris. The pain produces emotional reactions and the strongest of these is fear. Most of these patients know that their pain is resulting from an insufficient supply of oxygen to the heart and they frequently have a feeling of impending death. It usually helps to raise the patient to a sitting position so that breathing is less difficult. The prompt administration of nitroglycerin or the specific drug ordered by the physician should shorten the attack and relieve pain. Above all, the calm presence of someone who knows how to care for them can do much to reassure patients and help them relax, thus lessening the severity of the attack.
an·gi·na pec·to·ris(anji-nă pek-tōris)
Patients typically describe a pain or pressure located behind the sternum and having a tight, burning, squeezing, or binding sensation that may radiate into the neck, jaw, shoulders, or arms and be associated with difficulty in breathing, nausea, vomiting, sweating, anxiety, or fear. The pain is not usually described as sharp or stabbing and is usually not aggravated by deep breathing, coughing, swallowing, or twisting or turning the muscles of the trunk, shoulders, or arms. Women, diabetics, and the elderly may present with atypical symptoms, such as shortness of breath without pain.
In health care settings, oxygen, nitroglycerin, and aspirin are provided, and the patient is placed at rest. Morphine sulfate is given for pain that does not resolve after about 15 min of treatment with that regimen. Beta-blocking drugs (such as propranolol or metoprolol) are used to slow the heart rate and decrease blood pressure. They are the mainstay for chronic treatment of coronary insufficiency and are indispensable for treating unstable angina or acute myocardial infarction. At home, patients should rest and use short-acting nitroglycerin. Patients with chronic or recurring angina pectoris may get symptomatic relief from long-acting nitrates or calcium channel blockers. Patients with refractory angina may be treated with combinations of all of these drugs in addition to ranolazine, a sodium channel blocker.
The pattern of pain, including OPQRST (onset, provocation, quality, region, radiation, referral, severity, and time), is monitored and documented. Cardiopulmonary status is evaluated for evidence of tachypnea, dyspnea, diaphoresis, pulmonary crackles, bradycardia or tachycardia, altered pulse strength, the appearance of a third or fourth heart sound or mid- to late-systolic murmurs over the apex on auscultation, pallor, hypotension or hypertension, gastrointestinal distress, or nausea and vomiting. The 12-lead electrocardiogram is monitored for ST-segment elevation or depression, T-wave inversion, and cardiac arrhythmias. A health care provider should remain with the patient and provide emotional support throughout the episode. Desired treatment results include reducing myocardial oxygen demand and increasing myocardial oxygen supply. The patient is taught the use of the prescribed form of nitroglycerin for anginal attacks and the importance of seeking medical attention if prescribed dosing does not provide relief. Based on his needs, the patient should be encouraged and assisted to stop smoking, maintain ideal body weight, lower cholesterol by eating a low-fat diet, keep blood glucose under control (if the patient is diabetic), limit salt intake, and exercise (walking, gardening, or swimming regularly for 45 min to an hour every day). The patient is also taught about prescribed beta-adrenergic or calcium channel blockers and any other needed interventions should they become necessary.
Four major forms of angina are identified: 1. stable: predictable frequency and duration of pain that is relieved by nitrates and rest; 2. unstable: pain that is more easily induced and increases in frequency and duration; 3. variant: pain that occurs from unpredictable coronary artery spasm; and 4. microvascular: impairment of vasodilator reserve that causes angina-like chest pain even though the patient’s coronary arteries are normal. Severe and prolonged anginal pain is suggestive of a myocardial infarction.
|I||Ordinary physical activity, such as walking or climbing stairs, does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.|
|II||Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or in wind, under emotional stress, only during the few hours after awakening, or walking more than two level blocks and climbing more than one flight of stairs at a normal pace and in normal conditions.|
|III||Marked limitation of ordinary physical activity. Angina occurs on walking one to two level blocks and climbing one flight of stairs in normal conditions at a normal pace.|
|IV||Inability to carry on any physical activity without discomfort—angina symptoms may be present at rest.|
angina pectorisThe symptom of oppression, pain or tightness in the centre of the chest which occurs when the CORONARY arteries are unable to provide an adequate blood supply to meet the immediate demands of the heart muscle. Angina is almost always related to exercise or emotion and is relieved by rest. It is worse in cold conditions and after a meal. The symptom is often described as of a tight band round the chest. The pain may radiate down the arms, especially the left, or up into the neck or jaw. There may be associated breathlessness. Rapidly worsening angina, induced by ever-lessening amounts of exertion, is called unstable angina and requires urgent attention. Angina can be controlled with nitrates, especially nitroglycerine which is best taken in a tablet held under the tongue. The term derives from the Latin angere , to strangle and pectus , the breast. See also CORONARY SYNDROME.
Heberden,William, Sr., English physician, 1710-1801.
an·gi·na pec·to·ris(anji-nă pek-tōris)
Patient discussion about angina pectoris
Q. I still have chest pain after 5 angioplasties/stents. Does anybody else still have that much angina?