Stable angina -basics
Atherosclerosis affecting the coronary arteries –Coronary artery disease ( CAD ) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries , whether obstructive or non-obstructive (European Society of Cardiology 2019 )
Angina- most common symptom of Ischaemic heart disease
.Also known as typical angina- it is the occurrence of symptoms on exertion and alleviated at rest or with use of nitroglycerin
Unstable angina -Myocardial ischaemia at rest or on minimal exertion in the absence of acute myocardial necrosis ( part of ACS ) most common cause is a narrowing of the coronary artery as a result of a thrombus that develops on a disrupted atherosclerotic plaque and is nonocclusive other causes can include Prinzmetal angina-rare ( vasospasm of coronary artery ) the pain would be experienced at rest rather than on exertion.
Major risk factors for atherosclerotic heart disease diabetes smoking tobbacco hypertension lipid disorders Obesity genetic factors ( a family h/o IHD )
Causes of angina include imbalance between myocardial oxygen demand and supply coronary vasospasm aortic valve disease microvascular coronary dysfunction oesophageal spasm and reflux anaemia .
How common -Worldwide ischaemic heart disease is the leading cause of death and lost life years in adults Angina is derived from Latin – “angere” to strangle exact prevalence can be difficult to judge increases with age in both sexes women aged 45-64 yrs have a prevalence of 5 -7 % while men in the same range have a prevalence of 4-7 % , this increases to 10-12 % in women aged 65-84 yrs and 12-14 % BMJ reported that 250 000 angiograms were carried out with over 20,000 cases of angina Prevalence is higher in males
Obstructive coronary artery disease – traditional/historical cause – due to mismatch between myocardial supply and demand.
New evidence shows that vasomotor changes at the site of the epicardial coronary arteries and the coronary microcirculation can also trigger myocardial ischaemia in absence of obstructive coronary artery stenosis.
Microvascular angina Vasospastic angina-Ischaemia without obstructive coronary artery disease – INOCA.It is also important to note that often multiple mechanisms of myocardial ischaemia occurring in various coronary compartments can happen via different mechanisms. These can also coexist in combination.
Location-Usually located in the chest , near sternum but can be felt anywhere from epigastrium to the lower jaw or teeth between the shoulder blades in either arm to the wrist and fingers
Character-Described as pressure, tightness , heaviness , sometimes strangling , constricting or burning Some may describe this as discomfort rather than pain it may be associated with SOB other less specific symptoms as fatigue or faintness , nausea , burning , restlessness or a sense of impending doom
Duration-Usually discomfort is brief lasting for less than 10 min’s-more commonly just a few minutes or less Chest pain lasting a few seconds is unlikely due to CAD
Relationship to exercise-Symptoms can be precipitated by exertion -walking up an incline or against breeze , or in cold weather and disappear rapidly within a few minutes when these triggers stop Symptoms can also be exacerbated after a heavy meal or after waking up in the morning-these are classic angina features.
Assess for any manifestations for CVD and risk factors as family history of CVD , dyslipidemia , diabetes , hypertension , smoking and other lifestyle factors
Typical angina -Constricting discomfort in the front of the chest or in neck, jaw , shoulder or arm.
annual mortality rate of up to 3.2 % long term prognosis would be affected by variables as ventricular systolic function , extent of coronary artery disease , exercise duration or effort tolerance and co-morbid conditions Guidelines for management are available from NICE , ESC and are updated regularly
- Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence | ECR Journal
- Stable Angina – StatPearls – NCBI Bookshelf (nih.gov) Gillen C, Goyal A. Stable Angina. [Updated 2021 Jul 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559016/
- Angina – StatPearls – NCBI Bookshelf (nih.gov) Hermiz C, Sedhai YR. Angina. [Updated 2021 Jun 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557672/
- The Pathophysiology and Treatment of Stable Angina Pectoris (uspharmacist.com)
- Juhani Knuuti, William Wijns, Antti Saraste, Davide Capodanno, Emanuele Barbato, Christian Funck-Brentano, Eva Prescott, Robert F Storey, Christi Deaton, Thomas Cuisset, Stefan Agewall, Kenneth Dickstein, Thor Edvardsen, Javier Escaned, Bernard J Gersh, Pavel Svitil, Martine Gilard, David Hasdai, Robert Hatala, Felix Mahfoud, Josep Masip, Claudio Muneretto, Marco Valgimigli, Stephan Achenbach, Jeroen J Bax, ESC Scientific Document Group, 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC), European Heart Journal, Volume 41, Issue 3, 14 January 2020, Pages 407–477, https://doi.org/10.1093/eurheartj/ehz425
- Angina module 1: epidemiology – The British Journal of Cardiology (bjcardio.co.uk)