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What is Angina pectoris & definition of Angina pectoris.

Angina pectoris is the name given to episodes of chest pain caused by myocar- dial ischemia secondary to CAD. Angina affects around 1% of the adult population and its prevalence rises with increasing age. The severity and prog- noses of angina depends upon the degree of coronary artery narrowing and has a varied clinical presentation. The average annual mortality rate in the UK is about 4% per year.

Clinical features:

Angina is often unmistakable because the pain is precipitated by physical

exertion, particularly in cold weather, and is relieved by rest. Affected individuals

may describe a sense of tightness, heaviness, compression or constriction of the chest, sometimes radiating to the left arm or jaw. Emotion (anger or anxiety) and stress (fear or pain) can induce angina by leading to the release of

catecholamines (epinephrine [adrenaline] and norepinephrine [noradrenaline]) from the adrenal cortex. These hormones result in an increased heart rate (tachycardia), a raised blood pressure (reactive hypertension), and vasoconstriction of the coronary circulation. Consequently an increased cardiac workload is accom- panied by a paradoxical drop in blood flow and myocardial ischemia occurs – resulting in angina.

Variants of angina include:

  • Stable angina: pain only on exertion and relieved in a few minutes by rest and sublingual glyceryl trinitrate (GTN)
  • Decubitus angina: pain on lying down
  • Vasospastic (variant or Prinzmetal) angina: caused by coronary artery spasm
  • Acute coronary syndrome (unstable angina): angina at rest or of sudden onset with a rapid increase in severity. This is due to a transient subtotal

obstruction of a coronary vessel and is a medical emergency

  • Cardiac syndrome X: clinical features of angina but normal coronary arter- ies on angiogram. It is thought to be due to a functional abnormality of the coronary microcirculation.

Clinical signs

Some drugs such as nicorandil used in the management of unstable angina, can produce severe oral ulceration (Figure 1.5).

Diagnosis

The diagnosis of angina is primarily a clinical one. Physical examination and investigations may be normal. The individual’s risk factors for CAD should be carefully assessed.

Investigations may include:

  • Resting electrocardiogram (ECG): during pain there may be ST segment depression with a flat or inverted T-wave. The ECG is usually normal

between episodes of angina

  • Exercise ECG testing: positive in approximately 75% of people with severe CAD
  • Myocardial perfusion scans (thallium-201): to highlight ischemic myocardium
  • Coronary angiography: to assess coronary blood flow in diagnostically challenging cases. Occasionally gastro-esophageal reflux disease (GORD) and chest wall disease may mimic angina.

Management

Risk factors for CAD (cigarette smoking, physical inactivity, obesity,

hypertension, diabetes mellitus, hypercholesterolemia) should be identified and cor- rected. Prognostic therapies for angina include:

  • Aspirin: inhibits platelet aggregation by preventing the synthesis of throm- boxane A2
    • Glycoprotein IIb/IIIa receptor inhibitors: prevent adherence of fibrinogen to platelets and reduce thrombus formation, and are used in ‘high-risk’

individuals and patients with acute coronary syndrome

  • Lipid-lowering drugs (e.g. statins): have been shown to lower mortality rates in patients with CAD.

During acute episodes of angina, pain is relieved by administering oxygen, sublingual GTN and reducing anxiety. When angina occurs more frequently long-acting nitrates (isosorbide mononitrate), b-adrenergic blocking drugs (atenolol), and calcium antagonists (amlodipine) are used to reduce cardiac oxygen demands. For angina that fails to respond to medical measures, cardiac revascularization techniques should be considered:

  • Percutaneous transluminal coronary angioplasty (PTCA): stents (miniature wire coils) may be inserted into the coronary arteries to re-establish blood flow
  • Coronary artery bypass grafts: to bridge severe obstructions in patients with extensive CAD.

What is Atheroma ?

Atheroma (atherosclerosis) is character rised by the accumulation of cholesterol and lipids in the arterial intimal surface. Atheroma has a patchy distribution and, depending on the site and extent of disease, can give rise to a variety of clinical presentations (Table 1.1). A platelet–fibrin thrombus (clot) may form, break up and travel in the bloodstream (thrombo-embolism) with potentially life-threatening consequences. Alternatively, atheromatous plaques may rupture and ‘heal’ spontaneously.

Cardiovascular Conditions Definition ?

Listen to pronunciation. A type of disease that affects the heart or blood vessels. The risk of certain cardiovascular diseases may be increased by smoking, high blood pressure, high cholesterol, unhealthy diet, lack of exercise, and obesity.

Includes Diseases: Heart failure
Risk Factors: Obesity; Hypertension

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