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Angina pectoris is felt as discomfort in the chest or adjacent area and is caused by low blood flow to the heart (myocardial ischemia) that limits delivery of oxygen to the heart muscle during exertion. 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 gradual clogging of the artery with fatty buildup (atherosclerosis). However, 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 and cause angina.
Angina pectoris is classified 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 the angina pain is either different from regular angina pain, such as occurring more frequently, occurring more easily at rest, feeling more severe, or lasting longer; and Prinzmetal's 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 spasm of the coronary artery rather than because of actual blockage of the artery by plaque or clots.
Obesity, high blood pressure (hypertension), high cholesterol and lipids in the bloodstream (hyperlipidemia), low blood levels of high density lipoprotein, diabetes mellitus, and a positive family history of heart disease are major risk factors associated with coronary artery disease that may lead to angina. Other risk factors may include low red blood cell count (anemia), irregular heartbeat (arrhythmia), or overactive thyroid gland (hyperthyroidism).
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.
The incidence of angina over the age of 20 is highest in non-Hispanic black men and women (4.1% and 6.2%, respectively) and lowest in non-Hispanic white men and women (2.6% and 3.9%, respectively) (Alaeddini). Incidence and Prevalence: Approximately 350,000 new cases of angina pectoris are diagnosed each year in the US (Alaeddini). |
Source: Medical Disability Advisor
| History: Angina is typically described as discomfort beneath the breastbone with pressure, heaviness, or a weight-like sensation that may travel (radiate) across the chest into one or both arms and extend into the fingers. The discomfort may radiate to the back, between the shoulder blades, 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 and rarely can individuals 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 usually occurs in the morning rather than at the end of the day. Angina pain usually 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 or heart failure. Auscultation of the carotid arteries in the neck may identify abnormal sounds (bruits) suggesting atherosclerosis. Tests: Tests include the resting electrocardiogram (ECG) that examines the electrical activity of the heart and detects a new heart attack (myocardial infarction), a heart attack 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 cassette tape 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.
More sophisticated tests to look at the structure and function of the heart, 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. |
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 (vasodilating) 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 should keep nitroglycerin on hand at all times. 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 enteric-coated aspirin to inhibit blood clotting, lipid lowering agents, and estrogen therapy in women to reduce low-density lipoprotein and increase high-density lipoprotein.
Lifestyle changes such as limiting dietary fat intake, getting adequate exercise, and ceasing to smoke can minimize progression of coronary artery disease and decrease the frequency and severity of angina. Individuals who are anxious and nervous may be advised to seek counseling, and a mild tranquilizer may be prescribed. Overweight individuals should be encouraged to reduce weight, avoid high-calorie and high-cholesterol diets, abstain from gas-forming foods, and rest for short periods following meals. A high-fiber diet may lower serum cholesterol and triglyceride levels, decrease hypertension, and decrease the number and severity of anginal attacks. Diabetics should optimize control of their blood sugar levels. A regular program of daily exercise and immediate abstinence from smoking should be encouraged. Individuals should avoid "passive smoking" (being with a smoker or in a smoke-filled room) in order to reduce the risk of angina.
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), placement of a self-expanding device into the vessel at the site of obstruction (coronary stent), and a coronary artery bypass graft (CABG) where the obstructed part of the artery is surgically bypassed. |
Source: Medical Disability Advisor
| 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.
Individuals who undergo PTCA and/or implantation of a self-expanding device into the vessel at the site of occlusion (coronary stent) have a very low mortality rate associated with these procedures (1% to 3%). 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 will become blocked again (restenosis) and these individuals may need the procedure repeated. Alternatively, they may undergo a CABG. This procedure 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. Without risk factor modification such as ceasing to smoke, correcting high blood pressure and hyperlipidemia, and weight reduction the vessel may again become blocked after CABG. |
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 not 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 the 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. Eventually, the patient is advanced to higher levels of exercise with the addition of recreational activities as tolerated. This should be supplemented by an increase in daily lifestyle activities such as walking breaks at work, using stairs, gardening, and household work. 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 rib cage and/or sore chest muscles can also interfere with the rehabilitation process and should be addressed. |
Source: Medical Disability Advisor
| 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 a heart attack (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. Complications following acute heart attack can include circulatory shock, heart failure, fluid in the lungs (pulmonary edema), blood clot in the lungs (pulmonary embolism), and recurrent myocardial infarction. |
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 anginal attacks. Individuals may need to avoid lifting heavy weights. Brief rest periods throughout the work day may be helpful in avoiding attacks. |
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 electrocardiogram (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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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?
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) 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 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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Could individual benefit from a less demanding job situation, either physically or emotionally? Would individual benefit from participation in a cardiac rehabilitation program?
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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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 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 or coronary stent reopen the vessels or will individual require coronary artery bypass graft (CABG) surgery?
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Have any complications occurred such as heart attack or arrhythmia?
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Source: Medical Disability Advisor
| Alaeddini, Jamshid, Behzad Alimohammadi, and Jamshid Shirani. "Angina Pectoris." eMedicine. Eds. Alan D. Forker, et al. 26 Jul. 2004. Medscape. 14 Sep. 2004 <http://emedicine.com/med/topic133.htm>. |
Source: Medical Disability Advisor
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