Angina Pectoris

Angina Pectoris- Angina pectoris or chest pain is a clinical syndrome produced by insufficient Coronary blood flow leading to transient myocardial ischemia.

Risk Factors for Angina-

Myocardial Ishemia which occurs when there is 75 per cent or more block in a coronary artery due to arthroscleosis, forcing flow of blood through the stenosis vessel causing coronary artery spasm which is transient and reversible.

  • Advanced age
  • Coronary artery disease
  • Increase serum glucose levels (Diabetes)
  • Increase serum lipoprotein levels
  • Obesity
  • Hypertension
  • Smoking
  • Type A personality

Initiating Factors –

  • Cold weather
  • Heavy meals
  • Physical exertion
  • Hypoglycemia
  •  Strong Emotions
  • Stimulated drug abuse. e.g.-cocaine

What is ischemia?

Ischemia is a condition described as "cramping of the heart muscle." Ischemia occurs when the narrowed coronary artery reaches a point where it cannot supply enough oxygen-rich blood to meet the heart's needs.

 The heart muscle becomes "starved" for oxygen-rich blood to meet the heart's needs. The heart muscle becomes "starved" for oxygen. Ischemia of the heart can be compared to a cramp in the leg.

 When someone exercises for a very long time, the muscles in the legs cramp up because they're starved for oxygen and nutrients. Your heart, also a muscle, needs oxygen and nutrients to keep working. If the heart muscle's blood supply is inadequate to meet its needs, ischemia occurs, and you may feel chest pain or other symptoms.

Ischemia is most likely to occur when the heart demands extra oxygen. This is most common during exertion (activity), eating, excitement or stress, or exposure to cold. When ischemia is relieved in less than 10 minutes with rest or medications, you may be told you have "stable coronary artery disease" or "stable angina." Coronary artery disease can progress to a point where ischemia occurs even at rest. Ischemia and even a heart attack can occur without any warning signs and is called "silent" ischemia. Silent ischemia can occur among all people with heart disease, though it is more common among people with diabetes.

Types of Angina-

Stable angina- Chest pain occurring intermittently over a long period within the same pattern of onset, during and intensity of symptom.

  • Effort-induced pain from physical activity or emotional stress.
  • Relieved by rest
  • Predictable and reproducible

Unstable angina-This is unpredictable. A stable angina may develop into unstable angina. The angina will be occurring with increasing frequency minimal or no exercise, during sleep or even at total rest.

  • Pain occurs with increasing frequency
  • Has decrease response to therapy.
  • May signal an oncoming MI

Prinzmetal's angina or Variant Angina-It occurs at rest, usually in response to spasm of a coronary artery spasm may be due to increased myocardial oxygen demand, or increase in levels of substances like histamine, angiotensin, epinephrine, prostaglandin.

  • Pain due to coronary artery spasm.
  • Pain may occur at certain times of the day, but is note stress induced.

Nocturnal Angina- Angina occurs in the night, but not necessarily when the person is in recumbent position or during sleep.

Decubitus Angina-Angina occurs only while the person is lying down and is usually relieved by standing or sitting.

Symptoms of Angina-

  • Sever chest discomfort
  • Chest pain- May be mid-anterior chest, substernal, epigastric region, radiation to neck, back, arms, fingers
  • Sweating
  • Dizziness
  • Dyspnea

Onset and Duration-Gradual or sudden onset, usually duration of less than 15 minutes, relief from nitroglycerine.


  • History and physical examination
  • X-ray chest
  • Echocardiography, ECG
  • Lipid studies, enzyme series
  • Exercise ECG, Holter ECG
  • Nuclear Studies
  • PET
  • Coronary Angiography

 The doctor will ask questions about your medical history, do a physical exam and order routine blood tests. He or she may suggest one or more diagnostic tests as well, including:

Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An ECG can often reveal evidence of a previous heart attack or one that's in progress.

 In other cases, Holter monitoring may be recommended. With this type of ECG, you wear a portable monitor for 24 hours as you go about your normal activities. Certain abnormalities may indicate inadequate blood flow to your heart.

Echocardiogram. An echocardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing normally to your heart's pumping activity.

 Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery disease or various other conditions.

Stress test. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG. This is known as an exercise stress test. In

Some cases, medication to stimulate your heart may be used instead of exercise. Some stress tests are done using an echocardiogram. For example, your doctor may do an ultrasound before and after you exercise on a treadmill or bike. Or your doctor may use medication to stimulate your heart during an echocardiogram.

 Doctors may also use medications to stimulate your heart during an MRI. Doctors may use this imaging test to evaluate you for coronary artery disease.

 Another stress test known as a nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It's similar to a routine exercise stress test but with images in addition to an ECG. A tracer is injected into your bloodstream, and special cameras can detect areas in your heart that receive less blood flow.

Cardiac catheterization and angiogram. To view blood flow through your heart, your doctor may inject a special dye into your coronary arteries. This is known as an angiogram. The dye is injected into the arteries of the heart through a long, thin, flexible tube (catheter) that is threaded through an artery, usually in the leg, to the arteries in the heart.

This procedure is called cardiac catheterization. The dye outlines narrow spots and blockages on the X-ray images. If you have a blockage that requires treatment, a balloon can be pushed through the catheter and inflated to improve the blood flow in your coronary arteries. A mesh tube (stent) may then be used to keep the dilated artery open.

 Heart scan. Computerized tomography (CT) technologies can help your doctor see calcium deposits in your arteries that can narrow the arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely.

A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT scan, also can generate images of your heart arteries.


  • Treatment for coronary artery disease usually involves lifestyle changes and, if necessary, drugs and certain medical procedures.
  • Lifestyle changes
  • Making a commitment to the following healthy lifestyle changes can go a long way toward promoting healthier arteries:
  • Quit smoking.
  • Eat healthy foods.
  • Exercise regularly.
  • Lose excess weight.
  • Reduce stress.


Various drugs can be used to treat coronary artery disease, including:

  • Cholesterol-modifying medications- By decreasing the amount of cholesterol in the blood, especially low-density lipoprotein (LDL, or the "bad") cholesterol, these drugs decrease the primary material that deposits on the coronary arteries. Your doctor can choose from a range of medications, including statins, niacin, fibrates and bile acid sequestrants.
  • Aspirin- Your doctor may recommend taking a daily aspirin or other blood thinner. This can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries.

If you've had a heart attack, aspirin can help prevent future attacks. There are some cases where aspirin isn't appropriate, such as if you have a bleeding disorder or you're already taking another blood thinner, so ask your doctor before starting to take aspirin.

  • Beta blockers- These drugs slow your heart rate and decrease your blood pressure, which decreases your heart's demand for oxygen. If you've had a heart attack, beta blockers reduce the risk of future attacks.
  • Calcium channel blockers-These drugs may be used with beta blockers if beta blockers alone aren't effective or instead of beta blockers if you're not able to take them. These drugs can help improve symptoms of chest pain.
  • Ranolazine- This medication may help people with chest pain (angina). It may be prescribed with a beta blocker or instead of a beta blocker if you can't take it.
  • Nitroglycerin-Nitroglycerin tablets, sprays and patches can control chest pain by temporarily dilating your coronary arteries and reducing your heart's demand for blood.
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)-These similar drugs decrease blood pressure and may help prevent progression of coronary artery disease.

Procedures to restore and improve blood flow

  • Coronary artery stent
  • Coronary bypass surgery

 Sometimes more aggressive treatment is needed. Here are some options-

Special Therapeutic Procedure-

Percutaneous transluminal coronary angioplasty.stent placement, atherectomy, lazer angioplasty and coronary artery bypass graft.

  • Percutaneous transluminal coronary angioplasty (PTCA)-A specially designed balloon tipped catheter is introduced into the coronary artery to open the narrowed portion of the coronary artery. The catheter is passed through the femoral artery into the aorta and then into the affected coronary artery. Then the balloon is inflated and the atherosclerotic plaque is compressed against the arterial wall resulting in opening of the blocked lumen of the vessel.

  • Stent placement-Stents are expandable mesh-like structure designed to maintain vessel patency by compressing the arterial wall and resisting abrupt closure following PTCA. They are threaded on the PTCA catheter.

  • Atherectomy- A special device is used to shear off the atheromatus plague. this device is positioned is such a way that the dislodged plaque is sucked into the catheter.

  • Lazer Angioplasty-A catheter is introduced through a peripheral artery into the diseased coronary artery. A small leaser on the tip of catheter vaporizes the plaqued areas of the artery, facilitating the blood flow.

 Lifestyle and home remedies

  • Lifestyle changes can help you prevent or slow the progression of coronary artery disease.
  • Stop smoking. Smoking is a major risk factor for coronary artery disease. Nicotine constricts blood vessels and forces your heart to work harder, and carbon monoxide reduces oxygen in your blood and damages the lining of your blood vessels. If you smoke, quitting is one of the best ways to reduce your risk of a heart attack.
  • Control your blood pressure. Ask your doctor for a blood pressure measurement at least every two years. He or she may recommend more-frequent measurements if your blood pressure is higher than normal or you have a history of heart disease. Optimal blood pressure is less than 120 systolic and 80 diastolic, as measured in millimeters of mercury (mm Hg).
  • Check your cholesterol. Ask your doctor for a baseline cholesterol test when you're in your 20s and at least every five years. Most people should aim for an LDL cholesterol level below 130 milligrams per deciliter (mg/dL), or 3.4 millimoles per liter (mmol/L) If you have other risk factors for heart disease, your target LDL cholesterol may be below 100 mg/dL (2.6 mmol/L).
  • Keep diabetes under controlI. f you have diabetes, tight blood sugar management can help reduce the risk of heart disease. . Exercise helps you achieve and maintain a healthy weight and control diabetes, elevated cholesterol and high blood pressure — all risk factors for coronary artery disease. For example, try walking for about 30 minutes on most or all days of the week.
  • Participate in cardiac rehabilitation. If you've had surgery, your doctor may suggest you participate in cardiac rehabilitation — a program of education, counseling and exercise training that's designed to help improve your health.
  • Eat healthy foods. A heart-healthy diet, such as the Mediterranean diet, that emphasizes plant-based foods, such as fruits, vegetables, whole grains, legumes and nuts — and is low in saturated fat, cholesterol and sodium — can help you control your weight, blood pressure and cholesterol. Eating one or two servings of fish a week also is beneficial.
  • Avoid saturated fat and strans fat, excess salt, and excess sugar. If you drink alcohol, drink it in moderation — this means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
  • Maintain a healthy weight. Being overweight increases your risk of coronary artery disease. Losing even just a small percentage of your current weight can help reduce risk factors for coronary artery disease.
  • Manage stress. Reduce stress as much as possible. Practice healthy techniques for managing stress, such as muscle relaxation and deep breathing.
  • Get your flu shot. Get your flu (influenza) vaccine each year to reduce your risk of having influenza. In addition to healthy lifestyle changes, remember the importance of regular medical checkups. Some of the main risk factors for coronary artery disease — high `cholesterol, high blood pressure and diabetes — have no symptoms in the early stages. Early detection and treatment can set the stage for a lifetime of better heart health.

 Alternative medicine

  • Omega-3 fatty acids are a type of unsaturated fatty acid that's thought to reduce inflammation throughout the body, a contributing factor to coronary artery disease. However, some research has not found them to be beneficial. More research is needed. Fish and fish oil.
  • Fish and fish oil are the most effective sources of omega-3 fatty acids. Fatty fish — such as salmon, herring and light canned tuna — contain the most omega-3 fatty acids and, therefore, the most benefit. Fish oil supplements may offer benefit, but the evidence is strongest for eating fish.
  • Flax and flaxseed oil. Flax and flaxseed oil also contain beneficial omega-3 fatty acids, though studies have not found these sources to be as effective as fish. The shells on raw flaxseeds also contain soluble fiber, which can help with constipation. More research is needed to determine if flaxseed can help lower blood cholesterol.
  • Other dietary sources of omega-3 fatty acids. Other dietary sources of omega-3 fatty acids include canola oil, soybeans and soybean oil. These foods contain smaller amounts of omega-3 fatty acids than do fish and fish oil, and evidence for their benefit to heart health isn't as strong.

 Other supplements may help reduce your blood pressure or cholesterol level, two contributing factors to coronary artery disease. These include:

  1. Alpha-linolenic acid (ALA)
  2. Artichoke
  3. Barley
  4. Beta-sitosterol (found in oral supplements and some margarines, such as Promise Activ)
  5. Blond psyllium
  6. Cocoa
  7. Coenzyme Q10
  8. Garlic
  9. Oat bran (found in oatmeal and whole oats)
  10. Sitostanol (found in oral supplements and some margarines, such as Benecol)

Preparing for your appointment

 Early-stage coronary artery disease often produces no symptoms, so you may not discover you're at risk of the condition until a routine checkup reveals you have high cholesterol or high blood pressure. So it's important to have regular checkups.

 If you know you have symptoms of or risk factors for coronary artery disease, you're likely to see your primary care doctor or a general practitioner. Eventually, however, you may be referred toheart specialist (cardiologist).