Angina Pectoris Anti-Anginals

Angina Pectoris Anti-Anginals

Angina Pectoris

Angina Pectoris is the medical jargon applied to Chest Pain. Angina means pain (intense pain) and Pectoris means chest. In order to avoid confusion, it is used only for chest pain due to cardiac causes specifically stable angina.

Symptoms :Read more...

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Angina Pectoris

Angina Pectoris is the medical jargon applied to Chest Pain. Angina means pain (intense pain) and Pectoris means chest. In order to avoid confusion, it is used only for chest pain due to cardiac causes specifically stable angina.

Symptoms :

Chest pain, palpitations, sweating and anxiety following physical exertion. It would be relieved after some time or at rest.

Precipitating Factors:

Any activity that demands the heart to work harder results in the precipitation of an episode of angina. Some of the factors are as follows:

Common Factors:

  • Physical exertion

  • Cold Exposure

  • Heavy meals

  • Intense emotion

  • Sexual intercourse and orgasms

  • Straining hard

Uncommon Factors:

  • Lying flat(decubitus angina)

  • Vivid dreams(nocturnal angina)

  • Cardiac Features causing Angina are:

  • Any factors that cause disparity between the demand and supply of heart muscle blood supply and work results in angina pectoris.

Factors  influencing  myocardial oxygen  supply  and  demand:

  • Cardiac  Work

  • Heartrate

  • BP

  • Myocardial contractility

  • Left ventricularhypertrophy

  • Valve diseasee.g.aortic stenosis

Investigations:

Evaluation of angina involves putting the patient under stress and identify if an angina can be precipitated. Following are some of the possible investigations:

Resting ECG this would serve as the reference ECG or the reference status of the heart when the patient is asymptomatic and comfortable.

Exercise ECG - An exercise tolerance  test  (ETT)  is usually  performed using  a  standard  treadmill  or  bicycle  ergometer  while  monitoring  the  patient’s  ECG,  BP  and general  condition. Specific ECG changes suggestive of Angina pectoris may be identified in the ECG. Exercise  testing  is  also  a  useful  means  of  assessing  the severity  of  coronary  disease  and  identifying high-risk individuals. For example,  the  amount  of exercise  that  can  be  tolerated  and  the  extent  and  degree of  any  ECG segment  change  provide  a  useful guide  to  the  likely  extent of  coronary  disease.

Myocardial  perfusion  scanning-  This  may  be  helpful  in the  evaluation  of  patients  with  an  equivocal  or uninterpretable  exercise  test  and  those  who  are unable  to  exercise. It entails obtaining small pictures  of  the  myocardium  at  rest  and  during stress  (either  exercise  testing  or  pharmacological stress,  such  as  a  controlled  infusion  of  cardiotonic agents), after  the administration  of  an intravenous radioactive  isotope,  such  as  99 technetium tetrofosmin. Thallium  and  tetrofosmin  are  taken  up by  viable  perfused  myocardium.  A  perfusion  defect present  during  stress  but  not  at  rest  provides evidence  of  reversible  myocardial  ischaemia suggestive of Angina Pectoris or any other kind of angina  whereas  a  persistent  perfusion defect seen  during  both  phases  of  the  study  is  usually indicative of  previous  MI.

Stress  echocardiography-  This  is  an  alternative  to myocardial  perfusion  scanning  and  can  achieve similar  predictive  accuracy.  It  uses  transthoracic echocardiography  to  identify ischaemic segments of myocardium  and  areas  of  infarction.  The former  characteristically  exhibits  reversible  defects  in Stress echocardiography. Echocardiography uses a technique similar to ultrasonography where sound waves are sent using a probe and the reflected waves are collected to form an image and identify the blood flow to those areas.

Coronary angiography- This is a straightforward measure to identify any narrowing of the coronary arteries. Coronary arteries are the arteries supplying the heart muscles. When there is a filling defect indicative of atherosclerotic plaque in the coronary arteries, some kind of coronary artery disease (CAD) like stable angina, unstable angina or mycocardial ischemia or infarction may be the diagnosis.

Assessment of risk in Angina Pectoris:

High risk:

  • Post-infarct angina

  • Pooreffort tolerance

  • Ischaemia at low workload

  • Leftmainor three vessel disease

  • Poor LV function

Low risk:

  • Predictable exertional angina

  • Good effort tolerance

  • Ischaemia only at high workload

  • Single- vessel or two -vessel disease

  • Good LV function

Management of Angina Pectoris:

General Measures:

  • Careful  assessment  of  the  likely  extent  and severity  of  arterial  disease

  • The  identification  and  control  of  risk  factors  such  as smoking,  hypertension  and  hyperlipidaemia

  • The  use  of  measures  to  control  symptoms

  • The  identification  of  high-risk  patients  for  treatment to  improve  life  expectancy.

Medical Management:

  • Antiplatelet drugs like aspirin, clopidogrel which prevent the aggregation of platelets and hence the formation of any thrombus or embolus is prevented.

  • Antianginal drugs like nitrates, beta blockers, calcium channel blockers, nicorandil, ivabradine. These drugs act by either increasing the blood flow through the coronary arteries or decreasing the work load of the heart. Both of these help in Angina Pectoris.

Invasive Management:

Percutaneous coronary intervention (PCI)- Percutaneous coronary intervention (PCI) is performed by passing a fine guide wire across a coronary stenosis under radiographic control and using it to position a balloon, which is then inflated to dilate the stenosis. A coronary stent is a piece of coated metallic ‘scaffolding’ that can be deployed on a balloon and used to maximise and maintain dilatation of a narrowed vessel. The routine use of stents in appropriate vessels reduces both acute complications and the incidence of clinically important recurrence of Angina Pectoris. PCI provides an effective symptomatic treatment but definitive evidence that it improves survival in patients with chronic stable angina is lacking. It is mainly used in single- or two-vessel disease. Stenoses in bypass grafts can be dilated, as well as those in the native coronary arteries. The technique is often used to provide palliative therapy for patients with recurrent angina after CABG. Coronary surgery is usually the preferred option in patients with three-vessel or left main stem disease, although recent trials have demonstrated that PCI is also feasible in such patients.The main acute complications of PCI are occlusion of the target vessel or a side branch by a thrombus or a loose flap of intima (coronary artery dissection), and consequent myocardial damage. This occurs in about 2–5% of procedures and can often be corrected by deploying a stent; however, emergency CABG is sometimes required. Minor myocardial damage, as indicated by elevation of sensitive intracellular markers, occursin  up  to  10%  of  cases.  The  main  long-term  complication of  PCI  is  re-stenosis,  in  up to  one-third  of cases.  This  is  due  to  a  combination  of elastic  recoil  and smooth  muscle  proliferation  (neo-intimal  hyperplasia) and  tends  to  occur  within  3  months.  Stenting  substantially  reduces  the risk  of  re-stenosis,  probably  because it allows  the  operator  to  achieve  more  complete  dilatation  in  the  first  place.  Drug-eluting  stents  reduce  this  risk  even  further  by  allowing  an  antiproliferative drug, e.g.  sirolimus  or paclitaxel,  to  elute  slowly  from  the coating  and  prevent  neo-intimal  hyperplasia and in-stent re-stenosis.  There  is  an  increased  risk  of  late  stent  thrombosis  with  drug-eluting stents, although  the  absolute risk  is  small  (<  0.5%).  Recurrent  angina  (affecting  up  to 15–20%  of  patients  receiving  an  intracoronary  stent  at  6  months)  may  require  further  PCI  or  bypass grafting. The  risk  of  complications  and  the  likely  success  of  the procedure  are  closely  related  to  the  morphology  of  the stenoses,  the  experience  of  the  operator  and  the  presence of  important comorbidity, e.g.  diabetes,  peripheral  arterial  disease.  A  good  outcome  is  less  likely  if  the  target lesion  is  complex,  long,  eccentric  or  calcified,  lies  on  a bend  or within a  tortuous  vessel,  involves  a  branch  or contains  acute  thrombus. In  combination  with  aspirin  and  heparin,  adjunctive therapy  with  potent  platelet  inhibitors,  such  as  clopidogrel  or glycoprotein  IIb/IIIa  receptor  antagonists, improves  the outcome  of  PCI,  with  lower  short-  and long-term  rates  of  death  and  MI.

Coronary artery bypass graft: The  internal  mammary  arteries,  radial  arteries  or reversed  segments  of  the  patient’s  own  saphenous  vein can  be  used  to  bypass  coronary  artery stenoses.  This  usually involves  major  surgery  under  cardiopulmonary  bypass  but,  in  some  cases,  grafts  can  be applied  to  the  beating  heart:  ‘off-pump’  surgery.  The operative mortality  is  approximately  1.5%  but  risks are higher  in  elderly  patients,  those  with  poor  left  ventricular  function  and  those  with  significant  comorbidity,  such as  renal  failure. Approximately  90%  of  patients  are  free  of  angina  1  year  after CABG  surgery,  but  fewer  than  60%  of patients  are  asymptomatic  after  5  or  more  years.  Early postoperative  angina is  usually  due  to  graft  failure arising  from  technical  problems  during  the operation,  or  poor  ‘run-off’  due  to  disease  in  the  distal  native  coronary  vessels.  Late  recurrence  of  angina may  be  due  to progressive  disease  in  the  native  coronary  arteries  or graft degeneration. Fewer  than  50%  of  vein  grafts  are patent  10  years  after  surgery.  However,  arterial  grafts have  a  much  better  long-term  patency  rate,  with  more than  80%  of  internal  mammary artery  grafts patent at  10  years.  This  has  led  many  surgeons  to  consider  total arterial revascularisation  during  CABG  surgery.  Aspirin (75–150  mg  daily)  and  clopidogrel  (75  mg  daily)  both improve graft  patency,  and one  or  other  should  be  prescribed  indefinitely,  if well tolerated.  Intensive  lipid lowering  therapy  slows  the  progression  of  disease  in  the native  coronary  arteries  and bypass grafts,  and  reduces clinical  cardiovascular  events.  There is substantial  excess cardiovascular  morbidity  and  mortality  in  patients  who continue  to  smoke  after  bypass  grafting.  Persistent smokers  are twice  as  likely  to die  in  the  10  years following  surgery  than  those  who  give  up  at  surgery. CABG  improves  survival  in  symptomatic  patients with  left  main  stem  stenosis  or  three-vessel  coronary disease  or  two-vessel disease  involving  theproximal LAD coronary artery. Improvement in survival is most marked in those with impaired left ventricular function or positive stress testing prior to surgery and in those who have undergone left internal mammary artery grafting. Neurological complications are common, with a 1–5% risk of perioperative stroke. Between 30% and 80% of patients develop short-term cognitive impairment that typically resolves within 6 months. There are also reports of long-term cognitive decline that may be evident in more than 30% of patients at 5 years.

Prognosis of Angina Pectoris:

The prognosis of coronary artery disease is related to the number of diseased vessels and the degree of left ventricular dysfunction. A patient with single-vessel disease and good left ventricular function has an excellent outlook (5-year survival > 90%), whereas a patient with severe left ventricular dysfunction and extensive three-vessel disease has a poor prognosis (5-year survival < 30%) without revascularisation. Spon-taneous symptomatic improvement due to the develop-ment of collateral vessels is common.

Lifestyle Modifications:

  • Do not smoke
  • Aim for ideal bodyweight

  • Take regular exercise(exercise upto, but not beyond, the point of chest discomfort is beneficial and may promote collateral vessels)

  • Avoid severe unaccustomed exertion, and vigorous exercise after a heavy meal or in very cold weather

  • Take sublingual nitrate before undertaking exertion that may induce angina.


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