Angina pectoris, commonly known as angina, is chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels). In Medicine, chest pain is a Symptom of a number of serious conditions and is generally considered a Medical emergency. In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction Oxygen (from the Greek roots ὀξύς (oxys (acid literally "sharp" from the taste of acids and -γενής (-genēs (producer literally begetteris the Myocardium is the muscular tissue of the Heart. Relationship to other layers The other tissues of the heart are the Endocardium Coronary circulation is the circulation of blood in the Blood vessels that supply Blood to and from the Heart muscle Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries. Coronary disease (or coronary heart disease) refers to the failure of Coronary circulation to supply adequate circulation to Cardiac muscle and surrounding Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation The term derives from the Greek ankhon ("strangling") and the Latin pectus ("chest"), and can therefore be translated as "a strangling feeling in the chest". Greek (el ελληνική γλώσσα or simply el ελληνικά — "Hellenic" is an Indo-European language, spoken today by 15-22 million people mainly Latin ( lingua Latīna, laˈtiːna is an Italic language, historically spoken in Latium and Ancient Rome.

It is common to equate severity of angina with risk of fatal cardiac events. There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle (i. e. there can be severe pain with little or no risk of a heart attack, and a heart attack can occur without pain).

Worsening ("crescendo") angina attacks, sudden-onset angina at rest, and angina lasting more than 15 minutes are symptoms of unstable angina (usually grouped with similar conditions as the acute coronary syndrome). An acute coronary syndrome (ACS is a set of signs and symptoms ( Syndrome) related to the Heart. As these may herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack. Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply

Symptoms

Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms (often inner left arm), shoulders, and neck into the jaw. Radiation of pains denotes the characteristic of some types of pains to spread out to distant parts than the origin of the pain Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina.

Myocardial ischemia comes about when the myocardia (the heart muscles) receive insufficient blood and oxygen to function normally either because of increased oxygen demand by the myocardia or by decreased supply to the myocardia. In Medicine, ischemia ( Greek ισχαιμία, isch- is restriction hema or haema is Blood) is a restriction This inadequate perfusion of blood and the resulting reduced delivery of oxygen and nutrients, is directly correlated to blocked or narrowed blood vessels. In Physiology, perfusion is the process of nutritive delivery of Arterial Blood to a Capillary bed in the Biological tissue.

Some experience "autonomic symptoms" (related to increased activity of the autonomic nervous system) such as nausea, vomiting and pallor. &trade The autonomic nervous system ( ANS) (or visceral nervous system) is the part of the Peripheral nervous system that acts as a Control Nausea ( Latin: Nausea, Greek:, " Sea-sickness " also called wamble) is the sensation of unease and discomfort Vomiting (also called throwing up, emesis) is the forceful expulsion of the contents of one's Stomach through the Mouth and sometimes the Pallor (also called pastiness or wanness) is a reduced amount of oxy Hemoglobin in Skin or Mucous membrane, a pale color which can

Major risk factors for angina include cigarette smoking, diabetes, high cholesterol, high blood pressure, sedentary lifestyle and family history of premature heart disease. Tobacco Smoking is the inhalation of smoke from burned dried or cured leaves of the Tobacco plant most often in the form of a Cigarette. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Hypercholesterolemia (literally high blood cholesterol is the presence of high levels of Cholesterol in the blood. Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the Blood pressure is chronically elevated In Medicine, a family history consists of information about disorders that a patient's direct blood relatives have suffered from

A variant form of angina (Prinzmetal's angina) occurs in patients with normal coronary arteries or insignificant atherosclerosis. Prinzmetal's angina, also known as variant angina or angina inversa, is a syndrome typically consisting of angina (cardiac chest pain at rest that occurs It is thought to be caused by spasms of the artery. It occurs more in younger women.

Angina may further be classified as stable or unstable angina. Stable angina refers to the more common understanding of angina related to myocardial ischemia. Typical presentations of stable angina is that of chest discomfort and associated symptoms precipitated by some activity (running, walking, etc) with minimal or non-existent symptoms at rest. Symptoms typically abate several minutes following cessation of precipitating activities and resume when activity resumes. In this way, stable angina may be thought of as being similar to claudication symptoms.

Unstable angina may occur unpredictably at rest which may be a serious indicator of an impending heart attack. What differentiates stable angina from unstable angina (other than symptoms) is the pathophysiology of the atherosclerosis. In stable angina, the developing atheroma is protected with a fibrous cap. In Pathology, an atheroma (plural atheromata is an accumulation and swelling (-oma in Artery walls that is made up of cells (mostly Macrophage cells This cap (atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and further decrease the lumen of the coronary vessel. This explains why angina appears to be independent to activity.

Diagnosis

In angina patients who are momentarily not feeling any chest pain, an electrocardiogram (ECG) is typically normal, unless there have been other cardiac problems in the past. During periods of pain, depression or elevation of the ST segment may be observed. To elicit these changes, an exercise ECG test ("treadmill test") may be performed, during which the patient exercises to their maximum ability before fatigue, breathlessness or, importantly, pain supervenes; if characteristic ECG changes are documented (typically more than 1 mm of flat or downsloping ST depression), the test is considered diagnostic for angina. A cardiac stress test is a Medical test that indirectly reflects arterial Blood flow to the Heart during Physical exercise The exercise test is also useful in looking for other markers of myocardial ischaemia: blood pressure response (or lack thereof, particularly a drop in systolic pressure), dysrhythmia and chronotropic response. Other alternatives to a standard exercise test include a thallium scintigram (in patients that cannot exercise enough for the purposes of the treadmill tests, e. A cardiac stress test is a Medical test that indirectly reflects arterial Blood flow to the Heart during Physical exercise g. , due to asthma or arthritis or in whom the ECG is too abnormal at rest) or Stress Echocardiography. Asthma is a chronic Condition involving the Respiratory system in which the airways occasionally constrict become inflamed, and are Arthritis (from Greek arthro-, joint + -itis, inflammation plural arthritides is a group of conditions involving damage to the Joints of the body An echocardiogram is a Sonography of the Heart. Also known as a cardiac ultrasound it uses standard ultrasound techniques to image two-dimensional slices of

In patients in whom such noninvasive testing is diagnostic, a coronary angiogram is typically performed to identify the nature of the coronary lesion, and whether this would be a candidate for angioplasty, coronary artery bypass graft (CABG), treatment only with medication, or other treatments. A coronary catheterization is a Minimally invasive procedure to access the Coronary circulation and blood filled chambers of the Heart using a Catheter Angioplasty is the technique of mechanically widening a narrowed or totally obstructed Blood vessel; typically as a result of Atherosclerosis. Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure In patients who are in hospital with unstable angina (or the newer term of "high risk acute coronary syndromes"), those with resting ischaemic ECG changes or those with raised cardiac enzymes such as troponin may undergo coronary angiography directly.

Pathophysiology

Increase in heart rate results in increased oxygen demand by the heart. The heart has a limited ability to increase its oxygen intake during episodes of increased demand. Therefore, an increase in oxygen demand by the heart (eg, during exercise) has to be met by a proportional increase in blood flow to the heart.

Myocardial ischemia can result from:

1. a reduction of blood flow to the heart that can be caused by stenosis, spasm, or acute occlusion (by an embolus) of the heart's arteries
2. resistance of the blood vessels
3. reduced oxygen-carrying capacity of the blood. A stenosis ( Plural: stenoses; from Ancient Greek στένωσις "narrowing" is an abnormal narrowing in a Blood vessel In Medicine, an embolism occurs when an object (the embolus, plural emboli) migrates from one part of the Body (through circulation

Atherosclerosis is the most common cause of stenosis (narrowing of the blood vessels) of the heart's arteries and, hence, angina pectoris. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation A stenosis ( Plural: stenoses; from Ancient Greek στένωσις "narrowing" is an abnormal narrowing in a Blood vessel Some people with chest pain have normal or minimal narrowing of heart arteries; in these patients, vasospasm is a more likely cause for the pain, sometimes in the context of Prinzmetal's angina and syndrome X. Vasospasm refers to a condition in which Blood vessels spasm leading to Vasoconstriction. Prinzmetal's angina, also known as variant angina or angina inversa, is a syndrome typically consisting of angina (cardiac chest pain at rest that occurs The terms Syndrome X or Metabolic syndrome X may also be referring to Metabolic syndrome.

Myocardial ischemia also can be the result of factors affecting blood composition, such as reduced oxygen-carrying capacity of blood, as seen with severe anemia (low number of red blood cells), or long-term smoking. Blood is a specialized Bodily fluid that delivers necessary substances to the body's cells ��such as nutrients and oxygen—and transports Waste products Anemia ( AmE) or anæmia/anaemia ( BrE) (from the Ancient Greek grc-Latn anaîmia, meaning “without blood” is defined as a qualitative Tobacco Smoking is the inhalation of smoke from burned dried or cured leaves of the Tobacco plant most often in the form of a Cigarette.

Epidemiology

Roughly 6. 3 million Americans are estimated to experience angina. Angina is more often the presenting symptom of coronary artery disease in women than in men. The prevalence of angina rises with an increase in age. Similar figures apply in the remainder of the Western world. All forms of coronary heart disease are much less-common in the Third World, as its risk factors are much more-common in Western and Westernized countries; it could therefore be termed a disease of affluence. Third World is a name given to nations that are generally considered to be underdeveloped economically Diseases of affluence are those diseases which are thought to be a result of increasing wealth in a society in contrast to Diseases of poverty which result from impoverishment The increase of smoking, obesity and other risk factors has already led to an increase in angina and related diseases in countries such as China. Tobacco Smoking is the inhalation of smoke from burned dried or cured leaves of the Tobacco plant most often in the form of a Cigarette. Obesity is a condition in which excess Body fat has accumulated to such an extent that health may be negatively affected China ( Wade-Giles ( Mandarin) Chung¹kuo² is a cultural region, an ancient Civilization, and depending on perspective a National

Treatment

The main goals of treatment in angina pectoris are relief of symptoms, slowing progression of the disease, and reduction of future events, especially heart attacks and of course death. Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply An aspirin (75 mg to 100 mg) per day has been shown to be beneficial for all patients with stable angina that have no problems with its use. Aspirin, or acetylsalicylic acid (ASA (əˌsɛtɨlsælɨˌsɪlɨk ˈæsɨd is a Salicylate drug, often used as an Analgesic to relieve Beta blockers (eg. Beta blockers (sometimes written as β-blocker) are a class of drugs used for various indications but particularly for the management of Cardiac arrhythmias carvedilol, propranolol, atenolol etc. are some few examples) have a large body of evidence in morbidity and mortality benefits (fewer symptoms and disability and live longer) and short-acting nitroglycerin medications are used for symptomatic relief of angina. Nitroglycerin ( NG) ( US spelling also known as nitroglycerine, ( UK Spelling trinitroglycerin, trinitroglycerine Calcium channel blockers (such as nifedipine (Adalat) and amlodipine), Isosorbide mononitrate and nicorandil are vasodilators commonly used in chronic stable angina. Calcium channel blockers are a class of drugs and natural substances with effects on many excitable cells of the body like the muscle of the Heart, smooth muscles Nifedipine (brand name Adalat, Nifedical, and Procardia) is a Dihydropyridine Calcium channel blocker. Amlodipine (as Besylate, Mesylate or Maleate) is a long-acting Calcium channel blocker (dihydropyridine used as an Anti-hypertensive Isosorbide mononitrate is a drug used principally in the treatment of Angina pectoris and acts by dilating the Blood vessels so as to reduce the Blood pressure Nicorandil is a Drug used to treat angina. It is marketed under the trade names Ikorel (in the United Kingdom, Australia and most A new therapeutic class, called If inhibitor, has recently been made available: ivabradine provides pure heart rate reduction,. Ivabradine ( INN) (ɪˈvæbrədin is a novel Medication used for the symptomatic management of stable Angina pectoris. ^[1] leading to major anti-ischemic and antianginal efficacy. ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit and lastly, statins are the most frequently used lipid/cholesterol modifiers which probably also stabilise existing atheromatous plaque. ACE inhibitors, or inhibitors of '''A'''ngiotensin-'''C'''onverting '''E'''nzyme, are a group of Pharmaceuticals that are used primarily in treatment of Hypertension The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular

Surprising perhaps is that exercise is also a very good long term treatment for angina (but only particular regimes - gentle and sustained exercise rather than dangerous intense short bursts),^[2] probably working by complex mechanisms such improving blood pressure and promoting coronary artery collateralisation.

Identifying and treating risk factors for further coronary heart disease is a priority in patients with angina. This means testing for elevated cholesterol and other fats in the blood, diabetes and hypertension (high blood pressure), encouraging stopping smoking and weight optimisation. Hypercholesterolemia (literally high blood cholesterol is the presence of high levels of Cholesterol in the blood. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the Blood pressure is chronically elevated Smoking cessation is the effort to stop smoking Tobacco products Weight loss, in the context of Medicine or Health or Physical fitness, is a reduction of the total Body weight, due to a mean loss of fluid

Ranolazine (Ranexa) is a new class of anti anginal drug that was approved by the Food and Drug Administration (FDA)

Recently, University of Cincinnati medical researchers in cardiology have tried to use a non-invasive, non-surgical collecting tool to gather harvested erythropoietic bone marrow-based adult stem cells and coax them into regrowing new coronary blood vessels to supply the cardiac muscle's cells (cardiac myocytes) with oxygenated blood, with some success- leading to larger Phase 2 trials. Ranolazine, sold under the Trade name Ranexa by CV Therapeutics is an Antianginal medication The cardiac muscle is a type of involuntary striated Muscle found in the walls of the Heart.

The largest randomised trial of an anti-anginal drug to date is the ACTION trial. It included 7,665 patients with stable angina pectoris. ACTION demonstrated that the calcium channel blocker nifedipine (Adalat) prolongs cardiovascular event- and procedure-free survival in patients with coronary artery disease. For example new overt heart failures were reduced by 29% compared to placebo. This finding confirms the vascular-protective effects of nifedipine. ^[3]

References

Major studies

• Information on ACTION - A Coronary Disease Trial Investigating Outcome with Nifedipine GITS in Patients with chronic stable angina pectoris

External links

• British Heart Foundation - Angina
• Angina Pectoris Online Resource for nurses and those in similar professions.
• Angina Pectoris Animation Video 3D