Angina Pectoris

Overview

Angina Pectoris refers to the pain caused by myocardial ischaemia. Myocardial Ischaemia is usually caused by stenosis within the vessel decreasing blood flow to the muscle, but it can be caused by tachycardia, anaemia, aortic stenosis, left ventricular hypertophy and many other disease. Angina “latin choking”.

Definition

Angina Pectoris: Pain caused by myocardial ischaemia (not myocardial infarction)
Acute myocardial Infarction: Death of myocardial tissue because of inadequate blood flow
Acute coronary Syndrome: Coronary artery obstruction or rupture can result in a variety of ischaemic condition which fall under the term of acute coronary syndrome. This does not include stable angina.
Unstable angina is defined by the absence of biochemical evidence of myocardial damage. It is characterised by specific clinical findings of prolonged (>20 minutes) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of MI.

Aetiology & Risk Factors

Modifiable	Non-modifiable
Smoking	Increasing age
Hypertension	Male sex
Dyslipidaemia	Family history
Diabetes mellitus	Ethnicity
Obesity
Physical inactivity
High calorie intake diet
Psychological stress

Clinical Manifestation

Rule out acute coronary syndrome if presenting to Emergency. Stable angina chest pain typically resolves with rest.

Chest discomfort (non-sharp pain)
Dyspnoea
Fatigue
Nausea/Vomiting

Infographic on angina pectoris showing chest pain symptoms (dyspnoea, fatigue, nausea/vomiting) and risk factors list.

1/1

Myocardial Ischaemia will respond to nitrates almost immediately.

Chest wall tenderness suggests musculoskeletal pain and does not accompany angina.

Diagnosis

CAUSES OF CHEST PAIN BY BODY SYSTEMS
Cardiac	Respiratory	Gastrointestinal	Musculoskeletal	Psychogenic
Acute Coronary Syndrome	Pulmonary Embolism	Oesophageal rupture	Rib Fracture	Anxiety
Aortic dissection	Pneumothorax	Pneumomediastinum	Herpes Zoster	Panic attack
Pericarditis	Pulmonary Hypertension	Cholecystitis	Costochondritis
Stable Angina	Pneumonia	GERD
Endocarditis	Lung Cancer	Peptic ulcer disease
Cardiac tamponade	Bronchiectasis	Acute Pancreatitis

Investigations

Test to induce ischaemic chest pain

Exercise ECG
Stress echocardiography
Myocardial perfusion scanning

Classification

Angina is classified according to its temporal pattern and its relation to exertion

Stable angina – angina only on exertion
Unstable angina – angina on exertion or at rest
Crescendo angina –
Decubitus angina – angina by lying flat

Unstable Angina is part of Acute Coronary syndrome. Stable angina is NOT part of acute coronary syndrome.

Treatment

Non-pharmacological

Education
Smoking cessation
Alcohol limitation
Lose weight
Exercise
Healthy diet

Pharmacological (BANS)

Betablockers (calcium channel blockers if contraindicated)
Aspirin
Nitrates
Statins

Pharmacology

Aspirin is a COX 1/2 inhibitor. It prevents the production of Prostagladins (inflammation: fever and pain) and thromboxane (clotting). It is used to treat fever, osteoarthritis, heart conditions and stroke. Side effects: nausea/vomiting, dyspepsia, stomach ulcer or bleeding problems, headache, dizziness, tinnitus, renal dysfunction and Reye’s syndrome (particularly in children who have taken aspirin).

Pharmacology

Statins are competitive HMG-CoA reductase inhibitors, an enzyme normally responsible for producing cholesterol. By lowering the levels, they help prevent heart attacks and stroke. Side effects: Headache, difficulty sleeping, flushing of the skin, myalgia, liver enzyme dysfunction, nausea or vomiting, abdominal cramping or pain, bloating or gas and serious cases myositis and Rhabdomyolysis.

Acute Coronary Syndrome