Angina pectoris (patient information)

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 * Associate Editor(s)-In-Chief: Jinhui Wu, MD

Overview
Angina pectoris is chest pain or discomfort that occurs when your heart muscle does not get enough blood. It may feel like pressure or a squeezing pain in your chest. You may also feel pain in your shoulders, arms, neck, jaw or back. Sometimes it may feel like indigestion. Not as a disease, angina is one of symptoms of coronary artery disease (CAD), the most common type of heart disease. CAD happens when a fatty substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow. Thus, people cannot get enough oxygen-rich blood and angina occurs.

What are symptoms of angina pectoris?
Angina itself is the most important syptom of coronary artery disease. It is the signal of myocardial ischemia. There are other symptoms accopanying with angina as following,


 * Chest pain: It always focus on precordial region or behind sternum. Not all chest pain is related to coronary artery disease.
 * Feeling of chest pressure: Some people feel chest pressure just like a huge stone on your chest or like a rope stringing your chest.
 * Feeling of indigestion: Loss of appetite, nausea or vomiting may occur in part patient.
 * Pain in shoulders,arms,jaw or back: It is always accompanying with chest pain or discomfort.

Other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that problems can be diagnosed and treated as early as possible.

Who is at highest risk?
Studies have found a number of factors that may induce angina. The risk factors of coronary artery disease are as the same as Angina. It concludes bad lifestyle and cardiovascular diseases risk factors. Some you can change and some you can not change.

Risk factors you can change
 * Cigarette smoking: Cigarette somking has a close relationship with many cardiovascular diseases. Smokers' risk of developing coronary heart disease is 2–4 times than that of nonsmokers. Besides, it is also a powerful independent risk factor for sudden cardiac death in patients with coronary heart disease; smokers have about twice the risk of nonsmokers. Furthermore, cigarette smoking acts with other risk factors to greatly increase the hazard for coronary heart disease. People who smoke seem to have a higher risk of death from coronary heart diseases (and possibly stroke) but these risk isn't as great as cigarette nonsmokers'.
 * High blood cholesterol: As blood cholesterol rises, so does risk of coronary heart disease. A person's cholesterol level is greatly affected by diet.
 * Stress: Clinical researches demonstrate that stress may be a contributing factor for coronary artery disease. People under stress may overeat, start smoking or smoke more than they otherwise would. These behavior may increase the risk of incidence of cardiovascular diseases.
 * Weight: Overweight and fat, especially body mass index(BMI) higher than 28 are risk factor for angina. Controlling weight is an available way to decrease the incident of angina.
 * High blood pressure: Patients with Hypertension seem to have a higher risk to develope coronary artery disease. This is because that Hypertension decrease the reserve of coronary arteries.
 * Diabetes mellitus: Like hypertension, patients with diabetes mellitus seem to have a higher risk to develope coronary artery disease. Because diabetes mellitus damage both coronary arteries and myocardial capillary vessels.
 * Drinking too much alcohol: Data has demonstrated too much alcohol damage your arteries and myocardium.

Risk factors that you cannot change
 * Age: People being older than 65 years or more have more probobility to develope to coronary artery disease than younger.
 * Gender: Male is an independent risk factor to develope to coronary artery disease than female. Post-menopause women also have greater probobility than younger women.
 * Heredity: Person with a family history of cardiovascular diseases is more likely to develope to coronary artery disease than people without family history.
 * Race: African Americans are at a higher risk than other races.

Diagnosis
Some health problems may cause the similar symptoms with angina. So people with any of those symptoms should go to see the doctor to be diagnosed and treated as early as possible.


 * Electrocardiogram: This is the most important and painless procedure in which a healthcare professional will measure the electrical activity of your heart to find whether there are any heart abnormalities or irregular heart beats.
 * Echocardiogram: This is a painless test to identify whether some areas of your heart are not contracting normally.
 * Several blood tests: Blood tests such as CK-MB Test and troponins test can be done by your doctor to determine whether or not your heart is damaged.
 * Coronary angiography: This is an imaging test that involves the injection of a special dye into your coronary arteries so that visible images can be seen on x rays to show the inside of your coronary arteries and to determine whether or not there is any obstruction of blood flow.
 * Stress testing: The test is done when you are exercising. This makes it easier for doctors to diagnosis heart disease.

When to seek urgent medical care?
People with cardiovascular diseases family history or bad life-style should go to the doctor to follow-up. When one has the following symptoms, he/she need to seek urgent medical care:


 * Persistent and severe chest pain
 * Sudden drop in blood pressure
 * Shortness of breath
 * Angina or chest pain accompanying with sweating or nausea or discomfort in shoulders, arms, jaws, neck or abdomen

These symptoms suggest that the person need to go to hospital to verify whether there are acute coronary syndrome (ACS) or not.

Treatment options
Patients with angina have many treatment options. The options include general therapy, medications, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). The choice of treatment depends mainly on symptoms and the stenosis degree of coronary arteries. Your doctor can describe your treatment choices, the expected results of each, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.

General therapy:
 * Controlling your weight and waistline
 * Giving up smoking and alcohol
 * Doing some exercises regular
 * Managing stress

Medications:
 * Anti-platlet drugs: Clinical trials demonstrate that aspirin 75 mg to 100 mg per day is beneficial for all patients with stable angina that have no problems with its use. Patients with peptic ulcer can select other anti-platelet drugs such as clopidogrel or prasugrel under the direction of the doctors.
 * Beta blockers: Beta blockers can reduce the effect of excitement/physical exertion on heart rate and force of contraction, dilation of blood vessels and decrease the toxicity of catecholamine on myocardium. Usual drugs used in angina are β1-selective agents such as Betaxolol, Bisoprolol, Esmolol, Metoprolol and Nebivolo. Patients with asthma, severe conduction block or severe heart failure are not appropriate for beta blockers. You should take these type of medicines under doctor's direction.
 * Nitroglycerin (NG): Nitroglycerin can be converted to nitric oxide in the body, which is a natural vasodilator and can improve myocardial ischemia. Nitroglycerin can be used in tablets, ointment, solution for intravenous use, transdermal patches (Transderm Nitro®, Nitro-Dur®), or sprays administered sublingually (Nitrolingual Pump Spray®, Natispray®). Usual side effects include headache, hypotension and flushed face.
 * Calcium-channel blockers: Calcium-channel blockers can reduce myocardial oxygen demand and reverse coronary vasospasm, then improve blood supply by several pathways such as negative inotropic effect, negative dromotropic effect and negative chronotropic effect. Phenylalkylamine calcium channel blockers are the type that are used to treat angina. Usual drugs are Verapamil (Calan, Isoptin) and Gallopamil (D600). Usual side effect is bradycardia.
 * Angiotensin converting enzyme inhibitor (ACEI): Angiotensin converting enzyme inhibitor (ACEI) is widely used in cardivascular diseases. This includes a large group of drugs, such as Enalapril (Vasotec/Renitec), Ramipril (Altace/Tritace/Ramace/Ramiwin), Quinapril (Accupril), Perindopril (Coversyl/Aceon), Lisinopril (Lisodur/Lopril/Novatec/Prinivil/Zestril) and Benazepril (Lotensin). They can improve symptoms and prognosis of heart failure by several ways. Uasual side effects include dry cough and angioedema. Patients who can not tolerate cough are often switched to angiotensin II receptor antagonist. Patients with renal artery stenosis on both sides or severe renal impairment are not appropriate for angiotensin converting enzyme inhibitor (ACEI).
 * Statins: Statins are a group of cholesterol-lowering agents that can decrease LDL cholesterol (so-called "bad cholesterol") and raising HDL-cholesterol ("good cholesterol"). Clinical trials have demonstrated that the statins play an important role in both the primary and secondary prevention of coronary heart disease. Usual drugs include Atorvastatin (Lipitor), Cerivastatin (Lipobay),Fluvastatin (Lescol), and Lovastatin (Mevacor, Altocor), etc. Side effects include liver enzyme derangements, myalgias and muscle cramps. Patients need to check liver function and creatine kinase regularly under the direction of the doctors.

Percutaneous coronary intervention (PCI):
 * Coronary artery disease is the disease that blockages in the coronary arteries restrict the blood supply to the heart muscle. Removing these blockages in coronary artery can improve overall coronary flow and myocardial perfusion, then improve the symptoms of angina. The procedure that performed in the cardiac catherization lab is to expand coronary arteries by balloon or to place stents in coronary arteries to improve blood supply to coronary arteries. A catheter, a very small tube with a tiny deflated balloon on the end, is inserted through an incision in the groin area and pushed through to the diseased artery. Then the balloon is inflated to push open the artery. The balloon is removed once the artery has been fully opened. A stent may be placed during the procedure to keep the blood vessel open. Clinical trials have demonstrated that percutaneous coronary intervention (PCI) is a very effective and safe procedure to reopen blocked vessels and can improve the patient's condition.

Coronary artery bypass grafting (CABG):
 * Coronary artery bypass grafting is a surgery that reroutes the blood supply around a blocked section of the artery. During this procedure, surgeons remove healthy blood vessels such as a leg or the chest wall from the patient himself/herself. Then the vessels are attached to the diseased artery in such a way that the blood can flow around the blocked section. After surgery the doctors recommend a routine of increased physical activity to strengthen the heart muscles and a diet low in fat and cholesterol to prevent the vessels from obstruction.

Where to find medical care for Angina pectoris?
Directions to Hospitals Treating Condition

Diseases with similar symptoms
Other health problems may also cause similar symptoms. Go to see your doctor to verify your diseases as early as possible.
 * Shortness of breath: This is needed to discriminate from respiratory system diseases such as pneumonitis, pulmonary tuberculosis, etc.
 * Indigestion: This symptom should be discriminated from digestive system diseases such as gastritis, peptic ulcer, etc.
 * Pain in shoulders, arms, jaw or back: Your doctor may discriminate from scapulohumeral periarthritis, teeth diseases and etc.