Chronic stable angina historical perspective


 * Assistant Editor-In-Chief: Meagan Doherty, B.S.

Overview
Chronic stable angina is a form of chest pain characterized by an insufficient blood flow to the myocardium of the heart to match myocardial energy demands (ischemia). The term angina was originally derived from the Greek word ankhon and the Latin word pectus, which when combined, loosely translates as "a strangling feeling in the chest." Attempts to classify this disease state began as early as the 4th century B.C., when Lucius Annaeus Seneca first described the symptoms he was experiencing as "to have any other malady is to be sick; to have this is to be dying." Throughout history many renowned researchers and health care professionals have contributed to the understanding, definition, and recognition of angina.

Initial Description

 * Circa 1707, the Italian anatomist Giovanni Battista Morgagni attempted to describe an episode angina that preceded the onset of an aortic aneurysm.
 * Later, John Hunter, Edward Jenner and Caleb Hillier Parry also became influential contributors to the clinical definition and diagnosis of angina. John Hunter, a well known Scottish surgeon, personally suffered from angina, and subsequently died due to myocardial infarction.
 * In 1799, Edward Jenner became the first physician to identify a correlation between the existence of coronary arterial sclerosis and the presence of angina pectoris. Jenner was not the only one aware of this correlation; Caleb Hillier Parry also recognized the association between cardiovascular disease and the presence of angina. However, unlike Jenner, he attributed an attack of angina to a temporary paralysis of the heart and coined the term “syncope anginosa.”
 * At the Royal College of Physicians in 1768, William Heberden presented the first classic description of angina pectoris. His description was based upon his 40 plus years of clinical practice "in the chambers of the sick." His notes were first published in 1772. Subsequently, his classic description was translated from Latin and reissued in 1802, the year following his death. His description was published in the book Commentaries on the History and Cure of Diseases in the chapter titled Pectoris Dolor = Disorder of the breast. The concise and comprehensive definition of angina as presented in this text has never been matched.
 * The following quotations are taken from various fractions of his original lecture notes: :
 * "There is a disorder of the breast, marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and extremely rare, of which I do not recollect any mention among medical authors. The seat of it, and sense of strangling and anxiety, with which it is attended, may make it not improperly be called angina pectoris. Those who are afflicted with it are seized, while they are walking and more particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away, if it were to increase or to continue: the moment they stand still all this uneasiness vanishes”.
 * “After it has continued some months, it will not cease so instantaneous upon standing still; and it will come on, not only when the persons are walking, but when they are lying down, and oblige them to rise up from their beds every night for many months together; and in one or two very inveterate cases it has been brought on by the motion of a horse or a carriage, and even by swallowing, coughing, going to stool or speaking, or by any disturbance of mind”.
 * “But all the rest, whom I have seen, who are at least twenty, were men, and almost all above 50 years old, and most of them with a short neck, and inclining to be fat. When a fit of this sort comes on by walking, its duration is very short, as it goes off almost immediately upon stopping. If it comes on in the night, it will last an hour or two; and I have met one, in whom it once continued for several days, during all which time the patient seemed to be in imminent danger of death”.
 * “But the natural tendency of this illness be to kill the patients suddenly, yet unless it have a power of preserving a person from all other ails, it will easily be believed that some of those, who are afflicted with it, may die in a different manner, since this disorder will last, as I have known it more than once, near twenty years, and most usually attacks only those who are above fifty years of age. I have accordingly observed one, who sunk under a lingering illness of a different nature”.
 * “The os sterni is usually pointed to as the seat of this malady, but it seems sometimes as if it was under the lower part of it, and at other times under the middle or upper part, but always inclining more to the left side, and sometimes there is with it a pain about the middle of the left arm”.
 * The French physician, Nicolas François Rougnon de Magny wrote a letter containing an early description of angina derived from his experiences with a patient who suffered from angina and subsequently died in February 1768, four months prior to William Herberden’s letter. These accounts have been a cause of debate between French and English physicians regarding who first described angina.
 * In 1970, this debate was meticulously reviewed by Evan Bedford. He conclusively reported that Nicolas François Rougnon de Magny did not describe the same syndrome as William Heberden, namely effort angina also known as stable angina. It was speculated that Nicolas François Rougnon de Magny may have been describing unstable angina due to the nature of the patient’s death.
 * Later in history, textbooks of medicine written by Austin Flint in 1866 and William Osler in 1892 describe the occurrence of angina as rare. Paul Dudley White wrote: "angina pectoris was uncommon in my early professional years but, when the automobile came in the 1920s and the population became more prosperous and over nourished, the current epidemic of coronary heart disease, as shown mainly by the symptom angina pectoris, began and incidentally involved younger and younger men."