Angina pectoris - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Chest pain Patients complain of retrosternal constricting type of chest pain or discomfort. It is commonly seen with exertion but may occur at rest as well. Pain radiates to the left shoulder and or to the left jaw. In order to diagnose angina all the following three criteria should be met. Pain should be substernal, symptoms are precipitated by physical or emotional stress and they usually respond to rest and or to nitrates. Chest pain in angina pectoris does not last more than 10 minutes.
According to the New York Heart Association (NYHA) functional classification, patients who develop angina only with vigorous exercise is classified under the class I. if angina occurs with slightly more vigorous activity than usual or if it is prolonged it is classified under class II. Angina occurring with normal daily activities is class III and if occurs at rest it is class IV.
Chest pain
Patients complain of retrosternal constricting type of chest pain or discomfort. It is commonly seen with exertion but may occur at rest as well. Pain radiates to the left shoulder and or to the left jaw. In order to diagnose angina all the following three criteria should be met. Pain should be substernal, symptoms are precipitated by physical or emotional stress and they usually respond to rest and or to nitrates. Chest pain in angina pectoris does not last more than 10 minutes.
According to the New York Heart Association (NYHA) functional classification, patients who develop angina only with vigorous exercise is classified under the class I. if angina occurs with slightly more vigorous activity than usual or if it is prolonged it is classified under class II. Angina occurring with normal daily activities is class III and if occurs at rest it is class IV.
Reduced exercise tolerance Patients develop ischemic chest pain with exercise, hence they have reduced exercise tolerance. Reduced exercise tolerance
Patients develop ischemic chest pain with exercise, hence they have reduced exercise tolerance.
Palpitations Patients with vasospastic angina can have ventricular arrhythmia. Palpitations
Patients with vasospastic angina can have ventricular arrhythmia.
Risk factors of ischemic heart disease Hyperlipidemia, diabetes, hypertension, smoking, sedentary life style, obesity and positive family history of ischemic heart disease are recognized risk factors for ischemic heart disease. Risk factors of ischemic heart disease
Hyperlipidemia, diabetes, hypertension, smoking, sedentary life style, obesity and positive family history of ischemic heart disease are recognized risk factors for ischemic heart disease.

Clinicals - Examination

Fact Explanation
Obesity Obesity is a risk factor for the development of ischemic heart diseases. Both Body Mass Index (BMI) and waist circumference should be measured. Obesity
Obesity is a risk factor for the development of ischemic heart diseases. Both Body Mass Index (BMI) and waist circumference should be measured.
Tachycardia or arrhythmia Patients often have arrhythmia induced by myocardial ischemia. Tachycardia or arrhythmia
Patients often have arrhythmia induced by myocardial ischemia.
Hypertension Patients can have elevated blood pressure, which is a risk factor for the development of angina pectoris. Hypertension
Patients can have elevated blood pressure, which is a risk factor for the development of angina pectoris.
Pheripheral stigmata of hyperlipidemia Xanthelasma, xanthomata and corneal arcus are peripheral stigmata of hyperlipidemia. Pheripheral stigmata of hyperlipidemia
Xanthelasma, xanthomata and corneal arcus are peripheral stigmata of hyperlipidemia.

Investigations - Diagnosis

Fact Explanation
Resting electrocardiogram (ECG) Resting ECG can be normal in patients with angina pectoris. ECG may show evidence of left ventricular hypertrophy. Resting electrocardiogram (ECG)
Resting ECG can be normal in patients with angina pectoris. ECG may show evidence of left ventricular hypertrophy.
Stress ECG This is more sensitive and specific than the resting ECG. Stress ECG can identify inducible ischemia. Stress can be induced by either graded exercise or with pharmacological substances like digoxin. Stress ECG
This is more sensitive and specific than the resting ECG. Stress ECG can identify inducible ischemia. Stress can be induced by either graded exercise or with pharmacological substances like digoxin.
Coronary angiography This visualizes the lesion and the degree of stenosis. This is considered an alternative to stress ECG test. Coronary angiography
This visualizes the lesion and the degree of stenosis. This is considered an alternative to stress ECG test.
Stress echocardiography Regional wall motion abnormalities and wall thickening can be detected after stress. If subendocardial ischemia is induced by exercise, cardiac contractility decreases. Wall motion abnormalities appear before the onset of ischemic ECG changes. So stress echocardiography is better than the ECG stress test. Stress echocardiography
Regional wall motion abnormalities and wall thickening can be detected after stress. If subendocardial ischemia is induced by exercise, cardiac contractility decreases. Wall motion abnormalities appear before the onset of ischemic ECG changes. So stress echocardiography is better than the ECG stress test.

Investigations - Management

Fact Explanation
Fasting plasma glucose Assessment of fasting plasma glucose is needed to diagnose or to exclude the presence of diabetes, which is a common co-morbidity. Fasting plasma glucose
Assessment of fasting plasma glucose is needed to diagnose or to exclude the presence of diabetes, which is a common co-morbidity.
Lipid profile Total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, and triglycerides should be assessed in all patients with ischemic heart diseases. Lipid profile
Total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, and triglycerides should be assessed in all patients with ischemic heart diseases.
Full blood count Anemia is a precipitant cause for the development of angina, which is correctable. Full blood count
Anemia is a precipitant cause for the development of angina, which is correctable.
Renal function test This is indicated for baseline evaluation of patients’ fitness. Renal function test
This is indicated for baseline evaluation of patients’ fitness.
Exercise stress test Can evaluate the patient’s exercise tolerance and degree of myocardial ischemia. It can determine the severity of coronary artery obstruction and hence the prognosis. Horizontal or downsloping ST segment depression of 1mm or more is considered as positive. Exercise stress test
Can evaluate the patient’s exercise tolerance and degree of myocardial ischemia. It can determine the severity of coronary artery obstruction and hence the prognosis. Horizontal or downsloping ST segment depression of 1mm or more is considered as positive.
Nuclear stress test Patients who are unable to do exercise can be subjected to nuclear stress test. Dobutamine, adenosine or dipyridamole is used to induce cardiac stress. Nuclear stress test
Patients who are unable to do exercise can be subjected to nuclear stress test. Dobutamine, adenosine or dipyridamole is used to induce cardiac stress.
Echocardiogram Determines the ejection fraction. If the ejection fraction is low, surgical revascularization is preferred over medical management. Echocardiogram also detects regional wall motion abnormalities, which are indicative of reversible ischemia. Echocardiogram
Determines the ejection fraction. If the ejection fraction is low, surgical revascularization is preferred over medical management. Echocardiogram also detects regional wall motion abnormalities, which are indicative of reversible ischemia.
Chest X-ray Aids in diagnosing heart failure. Presence of alveolar edema, Kerley B lines, cardiomegaly and upper lobe diversion are suggestive of heart failure. Chest X-ray
Aids in diagnosing heart failure. Presence of alveolar edema, Kerley B lines, cardiomegaly and upper lobe diversion are suggestive of heart failure.

Management - Supportive

Fact Explanation
Health education Patients should be advised about the importance of adherence to a healthy lifestyle, with adequate exercise, weight reduction and dietary modifications. The known precipitating factors of angina should be better avoided and if present anemia, valvular heart diseases and arrhythmia should be treated. Patients with cardiovascular comorbidities like diabetes, hypertension and hypercholesterolemia should be taught about the importance of control of comorbidities. Health education
Patients should be advised about the importance of adherence to a healthy lifestyle, with adequate exercise, weight reduction and dietary modifications. The known precipitating factors of angina should be better avoided and if present anemia, valvular heart diseases and arrhythmia should be treated. Patients with cardiovascular comorbidities like diabetes, hypertension and hypercholesterolemia should be taught about the importance of control of comorbidities.
Dietary modifications Patients are advised to take a balanced diet with variety of food items. Fat and cholesterol rich food is better avoided. Calorie intake from fats should be less than 30% of the total. Dietary fibers should be increased. Complex carbohydrates are preferred to simple carbohydrates.
Consumption of salt should be reduced (less than 2.4 g/day).
Alcohol consumption should be stopped or at least cut down to safe limits.
Dietary modifications
Patients are advised to take a balanced diet with variety of food items. Fat and cholesterol rich food is better avoided. Calorie intake from fats should be less than 30% of the total. Dietary fibers should be increased. Complex carbohydrates are preferred to simple carbohydrates.
Consumption of salt should be reduced (less than 2.4 g/day).
Alcohol consumption should be stopped or at least cut down to safe limits.
Physical exercise It is recommended to exercise for 30 minutes preferably daily or at least most days of the week. Brisk walking at a rate of 3 to 4 miles per hour, swimming, cycling, occupational or recreational activities and yard or household work are recommended exercises. Physical exercise
It is recommended to exercise for 30 minutes preferably daily or at least most days of the week. Brisk walking at a rate of 3 to 4 miles per hour, swimming, cycling, occupational or recreational activities and yard or household work are recommended exercises.
Management of hypertension Hypertension is a risk factor for the development of ischemic heart diseases. In patients with hypertension and angina beta-blockers are considered as the first line antihypertensive in treatment. Management of hypertension
Hypertension is a risk factor for the development of ischemic heart diseases. In patients with hypertension and angina beta-blockers are considered as the first line antihypertensive in treatment.
Management of diabetes Diabetes is a comorbid risk factor for the development of ischemic heart disease. Management of diabetes
Diabetes is a comorbid risk factor for the development of ischemic heart disease.

Management - Specific

Fact Explanation
Coronary revascularization Coronary revascularization is preferred over medical management if the patient has left ventricular dysfunction and three-vessel disease or left main coronary artery disease. Coronary artery bypass grafts, angioplasty and percutaneous techniques achieve coronary revascularization. Coronary revascularization
Coronary revascularization is preferred over medical management if the patient has left ventricular dysfunction and three-vessel disease or left main coronary artery disease. Coronary artery bypass grafts, angioplasty and percutaneous techniques achieve coronary revascularization.
Nitrates A potent venodilator, which decreases venous return and reduces the preload. This reduces the work load on myocytes and hence the oxygen demand. Nitrates also dilate the coronary arteries and improves myocardial perfusion. Sublingual, buccal, oral, intravenous and topical preparations are available. Nitrates
A potent venodilator, which decreases venous return and reduces the preload. This reduces the work load on myocytes and hence the oxygen demand. Nitrates also dilate the coronary arteries and improves myocardial perfusion. Sublingual, buccal, oral, intravenous and topical preparations are available.
Beta-adrenergic blockers Beta-adrenergic blockers block beta1 and beta2 receptors on myocytes and decreases the heart rate and the force of contraction. This reduces the myocardial oxygen demand. Once the heart rate is reduced the diastole prolongs hence the duration of coronary perfusion also prolongs. Cardioselective beta blockers (acebutolol, atenolol, betaxolol, metoprolol) mainly block beta1 adrenergic receptors in the heart, hence they have minimal effects on airway contractility. Beta-adrenergic blockers
Beta-adrenergic blockers block beta1 and beta2 receptors on myocytes and decreases the heart rate and the force of contraction. This reduces the myocardial oxygen demand. Once the heart rate is reduced the diastole prolongs hence the duration of coronary perfusion also prolongs. Cardioselective beta blockers (acebutolol, atenolol, betaxolol, metoprolol) mainly block beta1 adrenergic receptors in the heart, hence they have minimal effects on airway contractility.
Calcium Channel Blockers (CCB) CCBs causes vascular smooth muscle relaxation and vasodilatation. CCBs also inhibit the sinus and atrioventricular nodes and reduce the heart rate. Calcium Channel Blockers (CCB)
CCBs causes vascular smooth muscle relaxation and vasodilatation. CCBs also inhibit the sinus and atrioventricular nodes and reduce the heart rate.
Antiplatelet drugs Aspirin inhibits the cyclooxygenase enzyme in the vascular endothelium and in the platelets, thereby inhibits the synthesis of prostaglandins, mainly thromboxane A2. Thromboxane A2 is a potent vasoconstrictor and platelet activator. This prevents platelet aggregation and vasoconstriction. Clopidogrel is also an antiplatelet drug which is also used in treatment. Antiplatelet drugs
Aspirin inhibits the cyclooxygenase enzyme in the vascular endothelium and in the platelets, thereby inhibits the synthesis of prostaglandins, mainly thromboxane A2. Thromboxane A2 is a potent vasoconstrictor and platelet activator. This prevents platelet aggregation and vasoconstriction. Clopidogrel is also an antiplatelet drug which is also used in treatment.
Lipid-lowering therapy This is effective in patients with hypercholesterolemia, which is a significant risk factor. Lipid-lowering therapy
This is effective in patients with hypercholesterolemia, which is a significant risk factor.
Antioxidants Antioxidants like vitamins A and E are believed to play a role in decreasing adverse cardiovascular events. Antioxidants
Antioxidants like vitamins A and E are believed to play a role in decreasing adverse cardiovascular events.
Electrical neuromodulation This is proved to be useful in refractory angina pectoris. In this method of treatment and electrode is implanted in the epidural space for pain relief. This is preferred if other treatment modalities cannot be used. Electrical neuromodulation
This is proved to be useful in refractory angina pectoris. In this method of treatment and electrode is implanted in the epidural space for pain relief. This is preferred if other treatment modalities cannot be used.

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