| name: | Angina |
| also known as: | Angina Pectoris; Myocardial Ischemia; Heart Pain; Chest Pain; Cardiac Pain; Stenocardia; Heberden's Syndrome; Unstable Angina; Risk Stratification; ICD 413, 413.9 |
| also see: | Variant Angina; Cardiac Arrest, Acute Coronary Syndrome; Heart Attack, Chest Pain; Angiogram; Angioplasty; CABG; ICD |
| description: | Angina is caused by decreased blood circulation due to disease in and around the heart muscle vessels, causing pain from the lack of oxygen, often brought on by coronary artery disease, work, stress, emotion, anger and excitement, cold air, eating, smoking. Risk factors include, high blood pressure, obesity, diabetes, smoking, high cholesterol levels, hyperlipidemia, anemia, family history, cardiomyopathy, aortic stenosis, aortic regurgitation, cor pulmonale, pulmonary hypertension, male. Angina can be classified into 4 types: 1. classic angina which is chest pain 2. angina equivalent which is shortness of breath or fatigue from angina 3. unstable angina which portends an impending heart attack 4. variant angina also called Prinzmetal's angina Angina can also be classified into low risk and high risk: 1. Low risk - a person with angina but who tends to be active, exercise, and only has EKG changes late in an EKG stress test. 2. High risk - a person with angina who is by nature sedentary, is not active, does not exercise, can not go very far on an EKG stress test and has EKG changes early in an EKG stress test. When the coronary artery flow becomes critically reduced, either from decreased perfusion or increased resistance, such as coronary artery disease, high blood pressure, aortic stenosis, an angina can be converted to either an unstable angina, acute coronary syndrome or a heart attack. Risk stratification involves determining those patients who have low risk angina, high risk angina, unstable angina, or acute myocardial infarction syndrome and the likelihood of progression, so that proper treatment options can be determined. Risk stratification is performed by angioplasty and/or heart perfusion scan. |
| signs & symptoms: | Includes chest pain, squeezing pressure, heavy chest sensation, jaw pain, neck pain, arm pain, paleness and sweating, often brought on by stress, cold, exercise, meals, smoking, and relieved by rest, NTG. |
| diagnosis: | Whereas the signs and symptoms of angina and a heart attack are similar, as described above, with a heart attack there is muscle damage and subsequently the pain is not usually relieved by stopping the activity, or by taking nitroglycerin (NTG), also called nitrates. Diagnosis of angina is made signs, symptoms, exam and EKG including ST segment depression or elevation, normal or inverted T wave. Cardiac enzymes are normal. A heart attack is when there is heart tissue damage. A cardiac arrest is when the heart quits beating and the person quits breathing. Further diagnosis includes EKG stress test and possibly an angiogram. Some people with angina go on to have an angioplasty at the time of the angiogram or even a CABG. Other tests used in the evaluation of angina might include nuclear scan, CT scan, high resolution CT scan called electron beam CT or EBCT, and MRI scan. Echocardiogram can be used to assess heart function such as left ventricular ejection fraction. Some of these tests are not widely available and also are not used in any emergent fashion. Differential diagnosis includes: unstable angina, variant angina, heart attack, gastric ulcer, duodenal ulcer, heartburn, cholecystitis, pneumonia, pneumothorax, pulmonary embolism, costochondritis, gallstones, pericarditis, pleurisy, cor pulmonale, pulmonary hypertension, aortic dissection, internal shoulder derangement. Clinical pearl: 20% of patients with angina attacks do not show EKG changes. |
| treatment: | Any chest pain, especially if one thinks it is of heart origin, needs to be evaluated by a doctor or a hospital emergency room. Angina can lead to heart attack, congestive heart failure, heart arrhythmia, or even a cardiac arrest. Angina is treated with diet, exercise, changing lifestyle, weight loss, and with medicines, such as: 1. Nitrates including quick-acting nitroglycerin (NTG) for acute attacks, which is a coronary artery vasodilator, as well as long acting nitrates including isosorbide mononitrate, isosorbide dinitrate, and nitroglycerin transdermal. Nitrates contraindicated with viagra 2. Low dose aspirin which is an antiplatelet drug to thin the blood out. Plavix is often given with aspirin. 3. Other antiplatelet drugs and anticoagulation drugs. The newer antiplatelet drug plavix is often added to aspirin therapy for severe angina, but is not given without aspirin. 4. Beta blockers that reduce oxygen demand by the heart, such as atenolol, metoprolol. 5. Calcium channel blockers that are vasodilators which will in turn, supply more blood to the heart such as verapamil (calan), diltiazem (cardizem), nifedipine (procardia), amlodipine (norvasc). 6. Ace inhibitors such as ramipril in patients with CAD, diabetes, left ventricular dysfunction have been shown to reduce heart attack and death. 7. Other heart medications such as cholesterol lowering drugs, especially the HMG CoA reductase inhibitors (statins) such as atorvastatin (lipitor), lovastatin (mevacor), pravastatin (pravachol) 8. Medications directed at underlying causes and risks such as high blood pressure (see below). In addition to aspirin +/- plavix, a common combination is nitrates plus calcium channel blockers +/- beta blockers. A bad combination is beta blockers + calcium channel blockers in patients with poor left ventricular function. Additionally, risk and aggravating factors should be treated and/or avoided, such as high blood pressure, congestive heart failure, arrhythmia, high cholesterol, strenuous activity, obesity, cold weather, emotional stress, and quit smoking. Unstable angina can also be treated with bed rest and oxygen. In some patients, severe angina and unstable angina might require angioplasty or even a CABG. Under the supervision of a doctor, herbal treatment of angina might include hawthorn, ginkgo, ginger root, yellow jasmine and motherwort. Viagra and nitrates should not be taken together. |
| prevention: | Treat underlying causes and risks, such as high blood pressure, smoking, obesity, anemia, alcoholism, high cholesterol and fatty diet, as well as lack of exercise. |
| outcome: | Minor angina can be treated with medicines, diet, exercise and a change in lifestyle. Failure to treat angina including underlying causes and risks can lead to arrhythmia, heart attack, congestive heart failure, and cardiac arrest. Duke Treadmill score is a way of determining a person's risk of dying from a heart attack due to angina and coronary artery disease. A Duke score greater than 5 is a low risk, Duke -10 to +4 is intermediate, and a score less than -11 is a high risk. |
skynetMD suggests the following:
| if: | If the person has a cardiac arrest, and the heart stops beating and the person stops breathing, begin CPR, and |
| go to: | Go to the phone and dial 911 |
| if: | If the person is having chest pain, especially for the first time, including pain into the neck, jaw, and arm, as well as sweating |
| go to: | Go to the hospital for emergency care or dial 911. |
| if: | If the person has a known diagnosis of angina, but the angina is different from the normal angina episodes, it may be either unstable angina (pre-heart attack) or it may be a heart attack |
| go to: | Go to the hospital for emergency care or dial 911. |
| if: | If the person has a diagnosis of angina, they should take prescribed medicines, lightly exercise according to doctor recommendations, lower weight, quit smoking, avoid large meals, lower cholesterol and salt intake, avoid sudden emotional and physical stress, including cold weather, and |
| go to: | Go to the pharmacy for prescribed medicines and "baby" aspirin, as recommended by the doctor. |
| if: | If the person would like a heart condition Internet Resource |
| go to: | Go to American Heart Association www.americanheart.org, Heart Information Network www.heartinfo.org/ |
Last updated 5/6/2008