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Angina pectoris is a clinical syndrome that occurs when low blood flow to the heart (myocardial ischemia) limits delivery of oxygen to the heart muscle during exertion. It is felt as discomfort and tightening in the chest that is sometimes accompanied by pain in the left arm, shoulders, or jaw. Usually, blood flow is decreased because of blockage within one or more of the coronary arteries supplying the heart muscle (coronary artery disease). This blockage is typically the result of a buildup of fatty deposits (plaque) that gradually block the flow of blood and oxygen in the artery (atherosclerosis). Atherosclerotic narrowing of the coronary artery is the most frequent source of cardiac ischemia and angina; however, endothelial damage or dysfunction in the heart, a sudden tightening or narrowing of the coronary artery (vasospasm), or severe narrowing of the aortic valve (aortic stenosis) may also interfere with coronary blood flow, reduce delivery of oxygen to heart tissue, and cause angina. Angina can also be caused by other mechanisms that reduce oxygen delivery, such as anemia (low red blood cell count and/or low hemoglobin), low blood pressure (hypotension), bradycardia, exposure to carbon monoxide, and inflammation.
Angina pectoris manifests in different forms, which can make differential diagnosis difficult. The various forms are divided into three basic types: stable angina, in which pain is present only during exertion or extreme emotional distress and disappears with rest; unstable angina, in which symptoms occur with increasing frequency and pain occurs more easily at rest, feels more severe, or lasts longer; and Prinzmetal angina, in which angina occurs at rest, when sleeping, or when exposed to cold temperatures. In the latter type of angina, symptoms are generally caused by transient spasms of the coronary artery rather than by actual blockage of the artery by plaque or clots. Cardiac syndrome X refers to the presence of all typical symptoms of angina pectoris but with no detectable coronary artery disease or spasm.
Two standard classification systems are used to describe angina and unstable angina. The New York Heart Association classifies angina as Class I, angina occurring only on strenuous activity; Class II, angina with more prolonged or rigorous activity than usual; Class III, angina with typical daily activity; and Class IV, angina that occurs at rest. The Braunwald classification system for unstable angina includes Class I, new onset of severe angina within 2 months with no pain at rest; Class II, pain at rest in the last month but not within the last 48 hours; and Class III, angina at rest within the last 48 hours (Ferri).
Risk: Tobacco use, sedentary lifestyle, and advanced age increase an individual's risk for angina pectoris. Deconditioned individuals who begin strenuous exercise programs also have increased risk. Other major risk factors associated with coronary artery disease and development of angina include obesity, high blood pressure (hypertension), high cholesterol and lipids in the bloodstream (hyperlipidemia), low blood levels of high-density lipoprotein (HDL), diabetes mellitus, and a positive family history of heart disease. Having a low red blood cell count (anemia), irregular heartbeat (arrhythmia), or overactive thyroid gland (hyperthyroidism) may also increase the risk of angina.
Risk increases with age and decreases after age 85 (Haber). Gender may be a risk factor, but studies disagree about the difference in prevalence between men and women. In one study, American women between the ages of 40 and 74 had a higher prevalence of angina than men in the same age group. A report by the Centers for Disease Control and Prevention (CDC), however, suggests that men have a higher prevalence (5.5%) than women (3.4%) (Haber). This difference could be explained by racial differences in the two study populations. The prevalence of angina in individuals over the age of 20 in the US, Puerto Rico, and the Virgin Islands is estimated to be highest and increasing in Hispanics (5%), followed by whites (4.2%) and non-Hispanic black men and women (3.7%) (Haber).
Incidence and Prevalence: Approximately 400,000 to 500,000 new cases of angina pectoris are diagnosed each year in the US (Alaeddini; Haber). About 9.8 million individuals experience angina each year, of which 785,000 have a new heart attack (myocardial infarction), and about 470,000 have a recurrent coronary attack (Alaeddini).
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Source: Medical Disability Advisor
History: Angina is typically described as discomfort beneath the breastbone, with pressure, heaviness, or a weight-like sensation that may radiate across the chest into one or both arms and extend into the fingers. The individual may report a sensation similar to intestinal gas. The discomfort may radiate to the back, between the shoulder blades, or to the upper abdomen, neck, left maxilla, mandible (jaw), or earlobes. Individuals with angina sometimes complain of a pressure sensation, tightness, or squeezing in the chest. Angina is a generalized sensation: it is rarely possible for individuals to point to the exact location of their discomfort.
Angina can be associated with shortness of breath, heavy sweating (diaphoresis), nausea, and vomiting. It can be brought on by exercise, stress, eating a heavy meal, or exposure to cold and wind. It occurs more often in the morning than at the end of the day. Angina pain lasts at least 30 seconds but not longer than 15 minutes and is often relieved with rest or nitroglycerin medication, or both.
Physical exam: The exam is usually normal in individuals with angina, but it may reveal findings associated with risk factors for angina such as high blood pressure, irregular heartbeat, or abnormalities seen with an overactive thyroid. Listening to the heart (auscultation) may reveal extra sounds associated with valve dysfunction, arrhythmias, or heart failure. Auscultation of the carotid arteries in the neck may identify abnormal sounds (bruits) suggesting atherosclerosis.
Tests: Laboratory evaluation includes assay of cardiac troponins to help identify myocardial necrosis; measurement of cardiac isoenzymes (i.e., creatine kinase [CK] and myocardial band [CK-MB]) to rule out heart attack; fasting glucose and fasting triglycerides; total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C); thyroid-stimulating hormone (TSH) level in older individuals; C-reactive protein and erythrocyte sedimentation rate (ESR) to evaluate inflammation level; hemoglobin, hematocrit and complete blood count (CBC) to investigate anemia; and serum homocysteine measurement as a predictor of survival in acute coronary syndromes.
Tests include the resting electrocardiogram (ECG), which examines the electrical activity of the heart and detects a new myocardial infarction, one that occurred sometime in the past, or acute changes indicating the heart muscle is not getting enough blood flow (myocardial ischemia). The graded exercise stress test examines the ECG and the individual's symptoms during exercise and is therefore more sensitive to detecting low blood flow to the heart than the routine ECG. Ambulatory Holter monitoring uses a recorder to observe the ECG for a 24-hour period while the individual goes about usual activities. This test is therefore more sensitive to low blood flow conditions during stress or exercise and to irregularities of heart rhythm that may occur only occasionally. About 50% of patients with stable angina and no history of heart attack will have a normal ECG taken at rest; abnormalities may be observed during an acute episode of angina (Ferri).
Chest x-rays may be useful in individuals with symptoms or a history of congestive heart failure or pulmonary disease.
More sophisticated tests to look at the structure and function of the heart and its arteries and valves include perfusion scintigraphy, radionuclide angiography, and 2-dimensional echocardiography. Selective coronary angiography is the most definitive diagnostic test for examining the coronary arteries, but it is also invasive. In order to demonstrate vasospasm as the cause of the angina, a drug called ergonovine may be injected directly into the coronary arteries during angiography.
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Source: Medical Disability Advisor
To relieve the immediate pain of angina, individuals are advised to sit down as soon as the discomfort begins and remain quiet until the pain stops. A short-acting nitrate (nitroglycerin) can be placed under the tongue (sublingually). This usually relieves the pain within several minutes by enlarging the diameter (vasodilation) of the coronary arteries and lowering the systemic blood pressure so the heart does not have to perform as much work. The individual suffering from angina is advised to keep nitroglycerin on hand at all times. Skin patches are also available for use during an angina episode. If pain is not relieved by a repeat dose, emergency medical attention is needed.
For ongoing treatment, long-acting nitrates are often given in combination with beta-blocking agents to decrease the number and severity of angina attacks. Long-acting nitrates can be taken orally or administered as a skin patch or paste (topically). Calcium channel blockers may also be prescribed to complement the antianginal action of vasodilators and beta-blockers. Other medical treatments that may be beneficial include regular use of low doses of enteric-coated aspirin to inhibit blood clotting, the use of lipid-lowering agents, and estrogen therapy in women to reduce LDL and increase HDL.
Lifestyle changes to modify preventable risk factors, if undertaken aggressively, can minimize progression of coronary artery disease and decrease the frequency and severity of angina. Overweight individuals are encouraged to reduce weight, avoid high-calorie and high-cholesterol diets, increase fiber content of the diet, eat smaller meals more often rather than consuming large meals, abstain from gas-forming foods, and rest for short periods following meals. A high-fiber diet effectively lowers serum cholesterol and triglyceride levels, decreases hypertension, and decreases the number and severity of angina attacks. Diabetics are encouraged to optimize control of their blood sugar levels. A regular program of daily aerobic exercise is encouraged. Immediate abstinence from smoking and avoidance of "passive smoking" (being with a smoker or in a smoke-filled room) are also advised to reduce the risk of angina. Individuals who are anxious and nervous may be advised to seek counseling, and a mild tranquilizer may be prescribed.
Invasive procedures designed to increase coronary blood flow and ease the symptoms of angina include inflation of a balloon in the artery at the site of obstruction (percutaneous transluminal coronary angioplasty, or PTCA), with or without placement of a self-expanding device into the vessel at the site of obstruction (coronary stent). This procedure is done more frequently in individuals with only one vessel occluded. Surgical procedures include coronary artery bypass graft (CABG), in which the obstructed part of the artery is surgically bypassed. These procedures are most often performed in individuals with left-side coronary disease or symptomatic 2- or 3-vessel coronary stenosis and in diabetic patients with obstructive heart disease.
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Source: Medical Disability Advisor
The prognosis varies for each individual with angina, based on the progression of the underlying coronary artery disease. Although coronary heart disease is the most frequent cause of death in men and women in the US (Haber), heart attack is preceded by angina in only 18% of cases (Alaeddini). Individuals with angina pectoris may remain stable for varying lengths of time, develop worsening symptoms (unstable angina), or progress to myocardial infarction or death. The prognosis for individuals treated only with medication depends on the severity and extent of ischemia, the presence or absence of complex cardiac arrhythmia, the site of vascular obstruction, the number of coronary vessels involved, how well the heart is functioning, and the extent that risk factors can be modified.
Treatment of angina with PTCA with or without implantation of coronary stent is associated with a low mortality rate (1% to 3%) (Alaeddini). Many individuals show marked improvement and no longer experience angina a year later. However, in a significant number of individuals (~30%), the PTCA/stent-treated vessel may become blocked again (restenosis), and these individuals may need to have the procedure repeated. Alternatively, they may undergo a CABG procedure, which has a mortality rate of less than 3% and is highly effective in alleviating anginal pain; however, different institutions vary widely in their complication rate depending on the expertise of the surgeons. If the individual does not reduce risk by ceasing to smoke, correcting high blood pressure and hyperlipidemia, and reducing weight, the vessel may again become blocked after initial or repeat PTCA or CABG.
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Source: Medical Disability Advisor
Cardiac rehabilitation can be very helpful and is often prescribed for individuals with angina pectoris. With a specifically designed exercise program, an individual with angina pectoris can decrease his or her chest pain and substantially improve fitness levels. Rehabilitation addressing angina pectoris is progressed throughout phases used in many other cardiac conditions.
Phase 1 often begins with low levels of exercise to prevent excessive stress and overexertion and promote overall mobility of the body. Exercise may begin in the coronary care unit of a hospital starting with low-level exercise in the supine position. The individual progresses with exercises to sitting and eventually to standing. Progressive walking (ambulating) and eventual stair climbing are an important part of individual's exercise program while hospitalized.
Phase 2 usually begins after the individual is discharged from the hospital. Individuals hospitalized because of angina pectoris usually begin at this phase. Goals are to improve functional capacity by increasing physical endurance and promoting return to activity. This is done in an outpatient setting such as a rehabilitation center. Individuals are typically attached to an ECG monitor, a device used to record the continuous electrical activity of the heart muscle. A physical therapist keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm, both during exercise and at rest.
Phase 3 continues in an outpatient setting such as a rehabilitation center. Usually 3 to 6 months have lapsed from the start of rehabilitation to this point. Depending on the individual's condition, this phase may last for several months. Individuals may stay involved with an outpatient program for up to a year to accomplish all their goals. The individual is advised to increase daily lifestyle activities such as taking walking breaks at work, using stairs, gardening, and performing household chores. Eventually, the patient is advanced to higher levels of exercise with the addition of recreational activities as tolerated. Individuals should also be encouraged to decrease weight and stop smoking if necessary, in addition to increasing daily exercise.
Modifications may be needed in the rehabilitation program if anxiety or musculoskeletal pain occurs. Relaxation techniques and counseling may help determine the sources of the anxiety. Inflammation of the cartilage of the ribcage and/or sore chest muscles can also interfere with the rehabilitation process and should be addressed.
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Source: Medical Disability Advisor
Complications occur as a result of progression of the individual's underlying coronary disease. If the coronary artery blockage causing angina is not reversed and blood flow is not restored either spontaneously or with treatment, the vessel may become permanently blocked and the heart muscle supplied by that artery may die, resulting in an acute myocardial infarction. Decreased blood flow to the heart muscle can also cause irregular heartbeat (arrhythmia) that can prevent the heart muscle from pumping blood effectively. Certain types of arrhythmia may also encourage blood clot formation, increasing the risk of heart attack and stroke. Complications following acute myocardial infarction include circulatory shock, heart failure, fluid in the lungs (pulmonary edema), blood clot in the lungs (pulmonary embolism), and recurrent myocardial infarction.
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Source: Medical Disability Advisor
Return to work may initially involve restriction to a lighter workload or part-time duty. Individuals with residual ischemia or impaired function of the heart muscle could require permanent restrictions. The individual with an active, hectic life at work or a very stressful job may have to adjust to a lower activity level to avoid bringing on angina attacks. Individuals may need to avoid lifting heavy weights. Brief rest periods throughout the work day may be helpful in avoiding attacks.
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Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have a history of coronary artery disease? Other risk factors for angina? Is there a family history of heart disease?
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Does individual describe pressure, heaviness, or a weight-like sensation in the area beneath the sternum? Does the pain radiate? If so, is it radiating across the chest, down one or both arms, and extending to the fingers? Does it radiate to the back, between the shoulder blades, upper abdomen, neck, earlobes, or jaw?
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Does individual experience shortness of breath, heavy sweating (diaphoresis), nausea, or vomiting?
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Was pain initiated by exercise, stress, eating a heavy meal, or exposure to cold and wind? Did it last 30 seconds to 15 minutes but no longer?
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Does individual take nitroglycerine? If so, was pain relieved after nitroglycerine was taken?
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Was a resting ECG done? Did it reveal any abnormalities or changes?
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Was a graded exercise stress test done? Was individual able to complete the test? Were abnormalities or changes noted on the stress test ECG?
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Has individual worn an ambulatory Holter monitor to record the ECG for a 24-hour period?
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Was a chest x-ray done to assess for congestive heart failure or pulmonary disease?
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Were appropriate laboratory tests performed to evaluate parameters associated with heart disease?
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Have perfusion scintigraphy, radionuclide angiography, or 2-dimensional echocardiography been performed?
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Was selective coronary angiography required to confirm the diagnosis?
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Was the diagnosis of angina pectoris confirmed?
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Regarding treatment:
- Does individual sit down as soon as discomfort begins and remains quiet until pain stops?
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Does nitroglycerin placed under the tongue (sublingually) or as a patch on the chest relieve pain within several minutes? Does individual keep nitroglycerin on hand at all times?
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Does individual know that if pain is not relieved by a repeat dose, emergency medical attention is needed?
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Does individual take long-acting nitrates, beta-blocking agents, and/or calcium channel blockers? What about low-dose enteric-coated aspirin, angiotensin-converting enzyme inhibitors, or estrogen therapy?
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Is individual compliant with all medication regimens? Would a change in medication be helpful?
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Has individual made required lifestyle and diet changes?
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Is individual diabetic and maintaining control of blood glucose?
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Could individual benefit from a less demanding job situation, either physically or emotionally? Would individual benefit from participation in a cardiac rehabilitation program?
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Regarding prognosis:
- Has individual developed worsening symptoms (unstable angina)?
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How severe is the ischemia, and how many vessels are involved?
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To what extent has the underlying coronary artery disease progressed?
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Does the individual have a complex cardiac arrhythmia?
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How well is the heart functioning?
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Has individual modified preventable risk factors? Does individual understand the consequences of not modifying risk factors?
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Did individual undergo PTCA and/or implantation of a self-expanding device into the vessel at the site of occlusion (coronary stent)? To what extent has individual improved?
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Have the vessels become blocked again (restenosis)? Will PTCA with or without coronary stent reopen the vessels, or will individual require coronary artery bypass graft (CABG) surgery?
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If individual has not undergone corrective surgical procedures to treat blocked arteries, would one of those procedures be beneficial now?
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Have any complications occurred, such as heart attack or arrhythmia?
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Is individual receiving regular cardiac care?
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Source: Medical Disability Advisor
| CitedAlaeddini, Jamshid, and Jamshid Shirani. "Angina Pectoris." eMedicine. Eds. Alan D. Forker, et al. 12 Aug. 2009. Medscape. 2 Oct. 2009 <http://emedicine.medscape.com/article/150215-overview>.Haber, Marc D., and Thomas A. Brunell. "Angina Pectoris." eMedicine. Eds. Jerry Balentine, et al. 15 Jun. 2009. Medscape. 2 Oct. 2009 <http://emedicine.medscape.com/article/761889-overview>. Ferri, Fred F. "Angina Pectoris (Chapter 3)." Practical Guide to the Care of the Medical Patient. 7th ed. Mosby Elsevier, 2007. MD Consult. Elsevier, Inc. 2 Oct. 2009 <http://www.mdconsult.com/das/book/body/172367380-2/919271583/1417/332.html>. |
Source: Medical Disability Advisor
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