The Most Common Symptom of Angina - Essay Example

In angina, the discomfort can be precipitated by physical exertion, eating, exposure to cold, or emotional stress (Alaeddini, 2006). It lasts for about 1 to 5 minutes and is typically relieved by rest or sublingual nitroglycerine. Pain occurring for a few seconds or lasting for many hours and which is above the mandible and below the epigastrium is not due to angina (Alaeddini, 2006). Also, the intensity of angina does not change with respiration, cough, or change in position. Other symptoms include palpitations, exertional dyspnoea, diaphoresis, nausea, and decreased exercise tolerance (Fenton 2007).

Classification of angina

     Angina can be classified based on the severity of symptoms or based on functional limitation.

Based on the Canadian Cardiovascular Society grading scale (Alaeddini, 2006)

Class I - Angina only during strenuous or prolonged physical activity

Class II - Slight limitation, with angina only during vigorous physical activity

Class III - Symptoms with everyday living activities, ie, moderate limitation

Class IV - Inability to perform any activity without angina or angina at rest, ie, severe limitation

Based on New York Heart Association classification (Alaeddini, 2006)

Class I - No limitation of physical activity (Ordinary physical activity does not cause symptoms.)

Class II - Slight limitation of physical activity (Ordinary physical activity does cause symptoms.)

Class III - Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.)

Class IV - Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest.)

Variants of angina

     Angina decubitus is a variant of angina that occurs typically in the night when the patient is in the recumbent position. Unstable angina is new-onset angina with a significant recent increase in frequency and severity of angina or angina at rest. The angina is of at least class-III severity (Alaeddini, 2006).

Etiology

1. Decreased myocardial blood supply due to increased coronary resistance in large and small coronary arteries due to coronary atherosclerotic lesion, coronary spasm, microvascular angina, systemic inflammatory or collagen vascular diseases, etc (Alaeddini, 2006).
2. Increased extravascular forces, such as severe LV hypertrophy caused by hypertension, aortic stenosis, or hypertrophic cardiomyopathy (Alaeddini, 2006).
3. Reduction in the oxygen-carrying capacity of the blood, such as elevated carboxyhemoglobin or severe anemia (Alaeddini, 2006).
4. Congenital anomalies of the origin and/or course of the major epicardial coronary arteries (Alaeddini, 2006).
5. Structural abnormalities of the coronary arteries like congenital coronary artery aneurysm, fistula, or ectasia (Alaeddini, 2006).

Risk factors

     The major risk factors for atherosclerosis include a family history of premature coronary artery disease, cigarette smoking, diabetes mellitus, hypercholesterolemia, or systemic hypertension. Other risk factors are LV hypertrophy, obesity, and elevated serum levels of homocysteine, lipoprotein-A, plasminogen activator inhibitor, fibrinogen, serum triglycerides, or low high-density lipoprotein (Alaeddini, 2006).

Treatment

General measures and modification of risk factors:

1. Control of risk factors like smoking, obesity, diabetes mellitus, hypertension, hyperlipidemia.
2. Improve lifestyle by walking every day, eating a healthy balanced diet, and decreasing stress.

Specific treatment:

1. Medical

     The mainstay of treatment for angina pectoris is sublingual nitroglycerin. It is used both for acute relief of symptoms and as prophylactic treatment during certain activities. Beta-blockers are also used for symptomatic relief of angina and the prevention of ischemic events. Calcium channel blockers can be used to control anginal symptoms in patients with a contraindication to beta-blockers and in those in whom symptomatic relief of angina cannot be achieved with the use of beta-blockers, nitrates, or both (Alaeddini, 2006). Antiplatelet drugs like aspirin or clopidogrel are given to prevent thrombus formation by inhibiting platelet aggregation.

2. Surgical

Coronary revascularization: The main revascularization procedures are percutaneous transluminal coronary angioplasty, with or without coronary stenting, and coronary artery bypass grafting. These are done in patients with left main artery stenosis greater than 50%, 2- or 3-vessel disease, LV dysfunction (ejection fraction, <45%), and in conditions where severe symptoms are present despite good medical therapy (Alaeddini, 2006).

Prognosis

    The prognostic indicators are LV function, severity and location of atherosclerotic lesions, and the response of symptoms to medical treatment. LV ejection fraction of 40% is a poor prognostic sign. Also, critical lesions of the left main and proximal left anterior descending coronary arteries are associated with a greater risk. Patients who continue to smoke after an MI have a 22-47% increased risk of reinfarction and death (Alaeddini, 2006).