Stable Angina Pectoris: Symptoms and Diagnosis - Essay Example

Stable Angina Pectoris: Symptoms and Diagnosis The term angina pectoris was introduced in 1772 by William Heberden to refer to a syndrome characterized by a strangling sensation and anxiety in the chest area during or after exercise. He was not able to correlate it to cardiac conditions which other experts accomplished through identification of its association by necropsy with patients who suffered coronary heart disease (Christensen 10; Fox et al. 3-9; Crea & Gaspardone 3767). At present angina pectoris is generally used to include conditions such as myocardial ischaemia, esophagus, lung or chest wall disorders. An extensive description for angina pectoris includes discomfort in the jaw, shoulder, upper limbs and back. Although there are efforts to specify use of angina pectoris for chest area discomfort caused by myocardial ischaemia linked with coronary artery disease, there are also known causes like aortic stenosis and hypertrophic cardiomyopathy (Task Force of European Society of Cardiology 395; Fox et al. 3-9). Angina pectoris is considered stable if it has been occurring for over a number of weeks without any major worsening. Stable angina pectoris normally occur in situations related to increased myocardial oxygen usage. Factors such as ambient temperature and emotional stress can, however, influence symptoms of stable angina pectoris from time to time (Crea & Gaspardone 3767; Christensen 10-11). On the other hand, unstable angina pectoris is characterized by a suddenly deteriorating pre-existing angina pectoris or abrupt appearance of angina during rest or light work. This is generally caused by atherosclerotic plaque rupture which leads to intracoronary thrombus formation. Some patients experience heightened coronary artery tone or spasm (Fox et al 4). Causes of Angina Pectoris "Angina pectoris is caused by an imbalance between the perfusion of the myocardium and the demands of the myocardium"(Crea & Gaspardone 3767; Christensen 10-11). The pathological condition giving rise to this imbalance is most often the atheromatous narrowing of the coronary arteries. To attain this medical condition, also referred to as stenosis, there must be at least 50 to 70 percent narrowing of the coronary artery. In such decrease in the inner diameter, the coronary blood flow is rendered inadequate to reach the metabolic demands of the heart during strenuous activities or exercise. The impact of stenosis is not limited to the degree of narrowing of the luminal diameter but also on the length and quantity of stenoses present in the coronary artery (Crea & Gaspardone 3767; Christensen 10-11). Vasoconstriction at the area of the atheromatous narrowing normally results to segmental abnormal function and dilatation of the left ventricle which cause a sudden drop in coronary blood flow. Coronary vasoconstriction, on the other hand, occurs because of curtailed diastolic filling period due to tachycardia and different hormonal actions. Patients with coronary artery disease have the potential risk of acquiring fissuring or rupturing plaque which usually results in platelet aggregation, abnormality of coronary blood flow or thrombotic coronary occlusion. Increased vasomotor tone or spasm arises from the release of substances from activated platelets. This condition crosses the threshold in which a diagnosis of unstable angina pectoris or evolving myocardial infarction is given (Fox et al 5). It is estimated that 30,000 to 40,000 per 1 million persons suffering from angina pectoris in countries with high number of patients with coronary heart disease. The incidence of angina pectoris is notably twice as high as in middle-aged men as in middle-aged women. This medical condition severely limits the lifestyle of patients such that those of working age are forced to apply for early retirement (Christensen 10; Fox et al. 3-9; Crea & Gaspardone 3767). Symptoms Stable angina pectoris symptoms are grouped into four major features. These are in terms of location, association with exercise, characteristics, and duration. The first two features are easily described by patients but had a hard time giving accurate description of the last two features (Task Force of European Society of Cardiology 395; Fox et al. 3-9). The first symptom feature is the typical location of angina pectoris which is in the retrosternal region. The pain may spread to both sides of the chest area and the upper limbs, wrists, neck and jaw. Most cases present a radiation of the pain to the left side of the limbs while there are cases that the back is included. Most patients report pain that starts in one of the peripheral areas mentioned above but extends later to the center of the chest and there are also cases wherein there is no pain in the central chest region at all (Fox et al. 3-9; Crea & Gaspardone 3767). The second symptom feature is the association with exercise. During exercise or other stressful activities, there is increased myocardial oxygen consumption which usually provokes angina pectoris. The pain is, however, quickly relieved by rest although some patients have reported experiencing angina even at rest. This latter condition can be a regarded as unstable angina, or due to alteration in the coronary artery tone or arrhythmias. Emotion is also considered a very strong aggravating factor of angina pectoris (Crea & Gaspardone 3767; Christensen 10-11). The third symptom feature is the characteristics of the angina pectoris. Generally, angina pectoris is regarded as a form of pain although patients often deny this and instead describe it as a form of discomfort. Discomfort descriptions by patients include strangling, pressure, tightness, heaviness, constricting, or burning sensation. Accompanying symptoms include shortness of breath, fatigue, faintness, dizziness, nausea, burping, anxiousness, restlessness, or a sense of imminent disaster (Christensen 10; Fox et al. 3-9; Crea & Gaspardone 3767). The fourth and last symptom feature is the duration of the pain. Angina pectoris induced by exercise is usually relieved on its own or rest with one to three minutes after stopping physical exercise. Very strenuous physical exercise on the other hand requires up to ten minutes or longer period for the pain to dissipate. Angina pectoris caused by emotion may be mitigated more slowly than anginal pain induced by exercise. Pain symptoms worsen with continued exertion such as climbing stairs. Angina in the morning or after eating has also been reported. The Canadian Cardiovascular Society has developed a grading system for the classification of angina pectoris. There are for classes of angina based on symptoms; these include Class I, II, III and IV (Fox et al. 3-9; Crea & Gaspardone 3767). Class I is characterized by anginal pain caused by strenuous or rapid or continued exertion at work or exercise. It is not induced by ordinary physical activities like walking or climbing inclines. Class II includes pain induced by ordinary activity. This includes limitation during rapidly climbing stairs or inclines. In addition, pain is also experienced when walking after meals, in cold weather, against the wind, or under emotional stress. Class III is characterized by obvious difficulty in performing ordinary physical chores such as walking one or two blocks of level surface or climbing a flight of stairs under normal circumstances. Class IV is distinguished by complete inability to perform any physical activity without experiencing discomfort or pain. This condition is advanced such that pain or discomfort is present even while resting (Task Force of European Society of Cardiology 395; Fox et al. 3-9). Diagnosis and Investigative Techniques Healthcare practitioners usually rely on patient history for the preliminary diagnosis of stable angina pectoris although additional investigative techniques are required for confirmation of this medical condition. Several strategies are applied depending on the history of the patient and available information regarding cardiac health. Thus, the investigation for new patients with suspected cardiac problems follows different steps compared to diagnosis for patients with known history of coronary artery disease (Crea & Gaspardone 3767; Christensen 10-11). For the differential diagnosis of angina pectoris, the four classes listed above are used as guide. If the four cardinal classifications are present, or even just two that are commonly observed, then the diagnosis of chronic stable angina is immediately established. This is in some cases not readily accepted and other diagnoses need to be evaluated. These include symptoms such as esophageal reflux, peptic ulcer and musculoskeletal disorders to name a few. It should also be noted that peptic ulcer, gallstones and anxiety are often associated with chest pains (Fox et al. 3-9; Crea & Gaspardone 3767). In terms of physical signs, there are no useful features that are specific to stable angina pectoris. The most indicative symptom is the aortic stenosis which is the causative agent of this medical condition. On the other hand, attack-related symptoms may include paleness, distress and sweatiness for persons suffering angina pectoris. In addition, some cases of heart murmur of mitral incompetence characterized by the presence of third or fourth heart sounds can also be observed (Christensen 10; Fox et al. 3-9; Crea & Gaspardone 3767). Looking for concomitant or co-existent metabolic and clinical abnormalities is also applicable. This includes obtaining a full lipid profile in addition to similarly important and appropriate clinical and laboratory tests specifically used to detect anemia, hypertension, thyroid problems and diabetes (Task Force of European Society of Cardiology 395; Fox et al. 3-9). There are three investigative strategies used for the diagnosis of angina pectoris. These are (1) through patient history, (2) functional assessment and (3) coronary angiography. For some cases, the patient's history is sufficient for the diagnosis of stable angina pectoris. Patient's history is usually accompanied by physical examination and a resting electrocardiogram. This strategy is sometimes enough for elderly patients with mild symptoms which are readily mitigated by medical therapy thus not requiring coronary interventions. The second strategy is anchored on a functional assessment of the occurrence or nonexistence of myocardial ischaemia. This strategy includes exercise testing with electrocardiography, exercise myocardial perfusion imaging, stress-echocardiography and exercise radionuclide angiography. The third strategy peruses patient's history, physical examination, electrocardiogram and goes straight to coronary angiography. But this approach is naturally performed for patients with unstable angina (Task Force of European Society of Cardiology 395; Fox et al. 3-9). In clinical experiences, the second strategy is the one commonly practiced. Functional assessment is usually required before or to complement angiography for patients with recurrent or chronic stable angina (Fox et al. 3-9; Crea & Gaspardone 3767). Recommendations for laboratory assessments for the initial diagnosis of Class I stable angina pectoris include fasting lipid profile, glucose, full blood count and creatinine level. Additional tests may be suggested for specific cases: markers of myocardial damage and thyroid function. For Class IIa, oral glucose tolerance test is recommended while for Class IIb, Hs-C-reactive protein, Lipoprotein A, Homocysteine, HbA1c and NT-BNP tests are required (Task Force of European Society of Cardiology 395; Fox et al. 3-9). Works Cited Christensen, H.W. "Musculoskeletal Chest Pain in Patients with Stable Angina Pectoris - Diagnosis and Treatment." Ph.D. Thesis. Faculty of Health Sciences, University of Southern Dernmark, 2004. Crea, F. and A. Gaspardone. "A New Look at an Old Symptom: Angina Pectoris." Circulation 96 (1997):3766-3773. Fox, K., Garcia, M.A., Ardissino, D., Buszman, P., Camici, P., Crea, F., Daly, C., De Backer, G., Hjemdahl, P., Lopez-Sendon, J., Marco, J., Morais, J., Pepper, J., Sechtem, U., Simoons, M., and K. Thygesen. "Guidelines on the Management of Stable Angina Pectoris: Full Text." European Heart Journal DOI:10.1093/eurheartj/ehl002: 1-63. Task Force of the European Society of Cardiology. "Guidelines: Management of Stable Angina Pectoris." European Heart Journal 18 (1997): 394-413. Read More