Angina Pektoris

Coronary artery disease (or ischemic heart disease) is a disease in which fatty deposits accumulate in the cells of the inner layer of the coronary arteries, obstructing blood flow.

ANGINA PECTORIS: General | Angina pectoris | Causes | Symptoms | Fat deposits in the coronary artery | Diagnosis | Cholesterol and Coronary Artery Disease | Forecast | Treatment | Treatment of stable angina pectoris | Treatment of unstable angina pectoris | Questions and Answers | Sources/references

Fatty deposits (atheroma or plaques) occur gradually and are widespread in the large branches of the two main coronary arteries, which surround the heart like a wreath and supply it with blood; the step-by-step process that leads to this is called atherosclerosis. Atheromas bend into the arterial lumen and narrow it.

As they multiply, their parts can break off and enter the bloodstream, or small blood clots can form on their surface.

Image: The primary complications of coronary artery disease are angina pectoris and heart attack.

The heart muscle (myocardium) needs a constant flow of oxygen-rich blood from the coronary arteries for normal contraction and blood pumping. As coronary artery narrowing progresses, insufficient blood flow (ischemia) occurs, causing heart failure. The most common cause of myocardial ischemia is coronary artery disease; this is also called ischemic heart disease. The primary complications of this disease are angina pectoris and heart attack.

Coronary artery disease occurs in people of all races but is especially common among whites. However, race is not as important a risk factor as an individual's lifestyle. The risk of coronary artery disease is remarkably increased by a highly fatty diet, smoking, and a sedentary lifestyle.

Even in Slovenia, cardiovascular diseases are the leading cause of death, and coronary artery disease is the most crucial individual cause of these diseases. Mortality from it is higher in men than in women, especially between the ages of 35 and 55; after this age, it also increases in women.

Angina pectoris

Angina pectoris is a transient pain or tightness in the chest that occurs when the heart muscle is not getting enough oxygen. The intensity of its work determines the heart's need for oxygen: the beat's speed, strength, and emotional stress increase the heart's work and, thus, the heart's need for oxygen. If the arteries are narrowed or blocked and blood flow to the muscle cannot increase enough to meet the increased need for oxygen, ischemia causes pain.

Causes

Usually, angina pectoris is caused by coronary artery disease. However, it can have other causes, including abnormalities of the aortic valve, especially aortic stenosis (narrowing of the aortic valve), aortic insufficiency (leaking of the aortic valve), and hypertrophic subaortic stenosis. B Because the aortic valve is close to the mouth of the coronary arteries, these changes reduce blood flow through the coronary arteries. Angina pectoris can also be caused by arterial spasms (sudden, transient arterial spasms), and severe anemia reduces the oxygen supply to the heart and thus provokes angina pectoris.

Symptoms

Not everyone who has ischemia experiences angina pectoris. Ischemia without angina pectoris is called silent ischemia. It is not known why ischemia is sometimes silent. The patient often feels angina pectoris as pressure or pain behind the sternum. The pain can also appear in the left shoulder or inside of the left arm, in the back, neck, lower jaw, or teeth, and sometimes in the right arm. Many patients report discomfort, not pain.

Video content: Angina pectoris - symptoms and pathology.

As a rule, angina pectoris is provoked by physical activity; it usually lasts no more than a few minutes and goes away during rest. In some people, it occurs predictably at a specific stress level. In others, it is unpredictable. It is often worse if exertion follows a meal and is usually worse in cold weather. Walking in the wind or moving from a warm room to cold air can trigger an angina attack. Emotional upheavals can also cause or worsen it. Sometimes, it is provoked by a strong emotion, even during rest or a dream during sleep.

Variant angina pectoris (also called Prinzmetal's angina pectoris) is caused by a spasm of one of the large coronary arteries on the surface of the heart. It is characterized by the pain occurring during rest, not during exertion, and certain electrocardiographic (ECG) changes accompany the attack. Unstable angina is one in which the pattern of symptoms changes.

Since the characteristics of angina pectoris in an individual patient usually remain constant, any change - e.g., more severe pain, more frequent attacks, or attacks during minor exertion or even rest - is profound. Such changing symptoms usually indicate rapid progression of coronary disease with increasing narrowing of the artery due to rupture of atheroma or the formation of a blood clot. The risk of a heart attack is very high, and unstable angina is an emergency.

Fatty deposits in the coronary artery

When fatty deposits accumulate in the coronary arteries, blood flow decreases, and the heart muscle lacks oxygen. A lack of oxygen in the heart muscle can cause severe problems and damage the heart tissue.

Image: Angina pectoris can be a sign of coronary heart disease.

Treatment of oxygen deficiency in the heart muscle focuses on correcting the underlying cause, which often requires treating coronary heart disease, restoring normal blood flow, and preventing further damage to the heart muscle.

Diagnosis

The doctor diagnoses angina pectoris primarily based on the patient's description of the symptoms. In the period between attacks - and sometimes even during the angina attack itself - physical examination and EKG often reveal little or no abnormalities. During an attack, the heart rate may increase slightly, the blood pressure may increase, and the doctor may hear a characteristically altered sound with a stethoscope. During an attack of typical angina pectoris, there are usually noticeable changes in the ECG. Still, in the periods between individual attacks, the ECG can be expected, even in patients with extensive disease changes in the coronary arteries.

When the symptoms are characteristic, the diagnosis is usually easy for the doctor. The type of pain, location, and relationship to exertion, meals, weather, and other factors help him make a diagnosis. Specific tests help determine the degree of ischemia and the presence and prevalence of coronary artery disease. Stress testing (an examination in which the subject walks on a treadmill while their ECG is monitored) helps assess the severity of coronary disease and the ability of the heart to respond to ischemia.

Image: ECG also helps to diagnose variant angina pectoris.

The findings can help determine whether coronary arteriography or surgery is needed. Radioisotope imaging and exercise testing often provide valuable information about a patient's angina pectoris. Radioisotope imaging confirms the presence of ischemia, discovers which part of the heart muscle is affected and how extensive it is, and shows how much blood flows into the heart muscle.

Exercise echocardiography examines how a device creates images (echocardiograms) from ultrasound waves reflected from the heart. The examination is harmless and shows the heart's size, the heart muscle's movement, the flow of blood through the heart valves, and their function. Echocardiograms are performed at rest and during maximum exercise. If the subject has ischemia, the pumping motion of the left ventricular wall is not normal.

Coronary arteriography is sometimes performed if the diagnosis of coronary artery disease or ischemia is uncertain. More often, it is used to determine the severity of coronary disease and to assess whether the patient needs an intervention to improve blood flow - coronary artery bypass surgery or angioplasty. In a small number of patients with typical symptoms of angina pectoris and an abnormal stress test result, coronary arteriography does not show pathological changes in the coronary arteries.

In some such patients, the small arteries in the heart muscle are abnormally narrowed. Many questions remain open about this disease, which some experts call syndrome X. The symptoms of this syndrome are usually improved by taking nitrates or beta-blockers. The prognosis for patients with syndrome X is good. In some patients, dynamic electrocardiography with a Holter monitor (portable battery-operated ECG recorder) shows abnormalities that indicate silent ischemia.

Image: Radioisotope imaging confirms the presence of ischemia.

Opinions about the importance of silent ischemia are not unanimous, but in general, the severity of coronary artery disease determines the degree of silent ischemia and, thus, the prognosis. An EKG also helps diagnose variant angina by detecting specific changes if an attack develops during rest. Angiography (film X-ray imaging of the arteries after injection of a contrast medium) sometimes reveals spasms in coronary arteries that do not have atheroma. Some patients are injected with certain drugs during angiography to induce spasm.

Cholesterol and coronary artery disease

The risk of coronary artery disease increases with an increase in the concentration of total cholesterol and low-density cholesterol (LDL cholesterol; lousy cholesterol) in the blood. The danger, however, decreases with an increase in the concentration of high-density cholesterol (HDL cholesterol; good cholesterol).

Diet affects the concentration of total cholesterol - and thus also the risk of coronary disease. The modern Western diet increases the concentration of total cholesterol. Changing your diet (and taking prescribed medications if necessary) can lower cholesterol levels. Reducing the concentration of total and bad cholesterol slows down or even reverses the progression of coronary disease.

Video content: If you have stable angina pectoris, should you have an artery-opening procedure?

Decreasing the concentration of bad cholesterol is most beneficial to patients with other coronary disease risk factors. Such factors include smoking, high blood pressure, obesity, physical inactivity, high triglyceride levels, genetic predisposition, and male steroids (androgens). Quitting smoking, lowering blood pressure, reducing weight, and increasing physical activity reduce the risk of coronary heart disease.

Forecast

Among the key factors that make it possible to predict what may happen to the patient are age, the extent of changes in the coronary arteries, the severity of symptoms, and the level of normal heart muscle function. The more the coronary arteries are affected and narrower, the worse the prognosis. The prognosis is surprisingly good in patients with stable angina pectoris and average pumping capacity (ventricular muscle function). Reduced pumping capacity considerably worsens the expected course.

Treatment

Treatment begins with an effort to prevent coronary artery disease, slow its progression, or reverse it by controlling known causes (risk factors) for it. Primary risk factors, e.g., high blood pressure and high cholesterol, should be treated immediately. Smoking is the most important preventable risk factor for this disease.

Image: Primary risk factors should be treated immediately.

Treatment of angina pectoris largely depends on the severity and stability of the symptoms. If symptoms are stable and mild to moderate, eliminating risk factors and using medication may be the most effective route. If the symptoms worsen rapidly, doctors usually decide to immediately admit the patient to the hospital and treat them with drugs. Suppose the symptoms do not abate significantly despite medication, diet, and lifestyle changes. In that case, angiography is considered, which makes it possible to assess the possibility of coronary artery bypass surgery or angioplasty.

Treatment of stable angina pectoris

Treatment is designed to prevent or reduce ischemia and minimize symptoms. Four types of drugs are available: beta blockers (beta blockers), nitrates, calcium antagonists, and antiplatelet drugs.

Beta-blockers inhibit the effects of the hormones adrenaline and noradrenaline on the heart and other organs. During rest, they slow down the heart rate (frequency); during exercise, they limit the increase in heart rate and thus reduce the need for oxygen. Beta-blockers and nitrates have been shown to reduce the risk of heart attack and stroke death and improve the long-term course in patients with coronary disease.

Nitrates, e.g., nitroglycerin, they dilate blood vessels. It is possible to use short-acting or long-acting if. A nitroglycerin tablet placed under the tongue (sublingual use) usually relieves an angina attack within 1 to 3 minutes; the effects of this short-acting nitrate drug last for 30 minutes. Patients with chronic stable angina pectoris should always carry nitroglycerin tablets or spray. It can be beneficial if the patient takes the pill just before he reaches the level of exertion that he knows will trigger an angina attack.

Video content: Symptoms and how to treat an angina attack.

Nitroglycerin can also be used by placing a tablet next to the gums or inhaling an oral spray, but sublingual use is most common. Long-acting nitrates should be taken from 1 to 4 times the cholesterol concentration and treated immediately. Smoking is the most important preventable risk factor for this disease.

Treatment of angina pectoris largely depends on the severity and stability of the symptoms. If symptoms are stable and mild to moderate, eliminating risk factors and using medication may be the most effective route. If the symptoms worsen rapidly, doctors usually decide to immediately admit the patient to the hospital and treat them with drugs. Suppose the symptoms do not abate significantly despite medication, diet, and lifestyle changes. In that case, angiography is considered, which makes it possible to assess the possibility of coronary artery bypass surgery or angioplasty.

Treatment of unstable angina pectoris

Patients with unstable angina pectoris are often admitted to the hospital to monitor drug therapy closely and may use other treatments if necessary. These patients are given drugs that reduce the blood's tendency to clot. They may be prescribed both heparin, an anticoagulant drug that inhibits clotting, and acetylsalicylic acid. They are also given beta-blockers and intravenous nitroglycerin to reduce the workload on the heart. If the drugs are not effective, coronary arteriography and angioplasty or bypass surgery may be necessary.

Coronary artery bypass surgery: This type of surgery (sometimes called bypass) is highly effective in patients with angina pectoris in whom coronary artery disease is not widespread. It can improve the ability to bear physical stress, relieve symptoms, and reduce the number of medications or doses needed. Bypass surgery is most likely to benefit patients with severe angina pectoris that does not improve after drug treatment, whose heart is functioning normally, who have not had a heart attack, and who do not have other conditions that would make surgery a risk (e.g., chronic obstructive pulmonary disease ).

Video content: Treatment of unstable angina and myocardial infarction.

For such patients, the mortality rate during non-urgent surgery is less than 1%, and the risk of heart damage (e.g., heart attack) is less than 5%. Approximately 85 percent of patients are free of symptoms after surgery, or their symptoms are significantly reduced. The operation is slightly more risky in patients who have a reduced pumping capacity of the heart (poor left ventricular function), heart muscle damage due to a previous heart attack, or some other cardiovascular problem.

Bypass surgery means the insertion of a venous or arterial graft from the aorta (the main artery through which blood flows from the heart throughout the body) to the coronary artery; the graft is guided past the narrowed area (bypass or bypass). Veins are usually taken from the legs. Most surgeons also use at least one artery as a graft. It is usually taken from under the sternum.

Coronary disease rarely develops in these arteries. More than 90 percent are still functioning well ten years after surgery. Vein grafts can gradually narrow. After five years, a third or more of them are entirely impassable. In addition to improving angina symptoms, bypass surgery improves the prognosis for some people - especially those with severe disease.

The reasons for angioplasty in patients with angina pectoris are similar to those for bypass surgery. However, not all coronary artery narrowings are suitable for angioplasty treatment, due to their location, length, severity of calcification and other circumstances. Therefore, doctors carefully assess whether the patient is suitable for such an intervention.

The doctor first inserts a large needle into a large peripheral artery, usually the femoral artery in the groin. Through it, he introduces a long guide wire into the arterial system, the aorta, and the narrowed coronary artery. A catheter with a balloon at the tip is inserted along the guide wire into the affected coronary artery. Place it so that the balloon is at the point of constriction. Then, the balloon inflates for a few seconds. Inflating and deflating can be repeated several times.

Image: Doctors successfully open 80 to 90 percent of the affected arteries they reach.

The patient is carefully monitored during the procedure because the balloon's inflation momentarily interrupts blood flow through the coronary artery. Such arrest provokes ECG changes and ischemic symptoms in some people. The inflated balloon compresses the atheroma, widens the artery, and partially ruptures the inner layer of the arterial wall. If the angioplasty is successful, the obstruction is significantly reduced. Doctors successfully open 80 to 90 percent of the affected arteries they reach.

1 to 2 percent of patients die during angioplasty, and 3 to 5 percent experience a fatal heart attack. In 2 to 4 percent of patients, bypass surgery should be performed immediately after angioplasty. In about 20 to 30 percent, the coronary artery narrows again within six months - often, this happens already in the first few weeks after the procedure.

Angioplasty is often repeated and can successfully control coronary disease for a long time. To prevent re-narrowing after angioplasty, the doctor can use a newer method, inserting a wire mesh into the artery, the so-called i. vascular brace. Placing a splint appears to halve the risk of later arterial obstruction.

Few studies have compared the success of angioplasty with the success of drug therapy. Angioplasty is believed to be about as successful as bypass surgery. A study comparing bypass surgery with angioplasty found that after angioplasty, recovery time was shorter, and mortality and the risk of heart attack remained about the same over the two-and-a-half years that the study lasted.

Image: Placing a splint halves the risk of later arterial obstruction.

Among the newer methods for removing atheroma, many of which are still being tested, is using devices for drilling thick, fibrous, and calcified changes. However, these bypass surgery and angioplasty methods are always mechanical interventions to correct the immediate problem and do not cure the underlying disease. To improve the overall prognosis, the patient must influence the risk factors.

Questions and answers

What are the most common causes of the development of coronary artery disease?

Coronary disease is caused by damage to the inner layer of the coronary artery. The following factors can cause damage:

• smoking
• high blood pressure
• high cholesterol level
• diabetes or insulin resistance
• passive lifestyle
• radiation therapy in the breast area^[1]

How effective is the treatment of unstable angina pectoris?

The treatment of unstable angina pectoris depends on individual circumstances and the severity of the condition. It is essential to discuss your condition and treatment plan with your cardiologist. Timely and appropriate treatment can reduce the risk of heart complications.

How is angina pectoris diagnosed?

The doctor diagnoses angina pectoris primarily based on the patient's description of the symptoms. During an attack of typical angina pectoris, there are usually noticeable changes in the ECG, but the ECG can be expected in the periods between individual attacks.

Can angina pectoris be fatal?

It is usually not life-threatening, but it is a warning sign that you could be at risk of a heart attack or stroke. With treatment and healthy lifestyle changes, angina can be controlled, and the risk of more severe problems can be reduced^[2].

Can high cholesterol lead to the development of angina pectoris?

Angina (both stable and unstable) occurs when any cause causes narrowing of the coronary arteries. This can also include high cholesterol^[3].

Sources and references

1. Coronary artery disease - https://www.humanitas.net
2. Angina - https://www.nhs.uk
3. Causes of angina - https://www.news-medical.net