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Saturday, August 16, 2025

Angina


Definition and Overview
Angina, also known as angina pectoris, is chest pain or discomfort that occurs when the heart muscle does not receive enough oxygen-rich blood. It is a clinical manifestation of underlying coronary artery disease (CAD), which is caused by the narrowing or blockage of coronary arteries due to atherosclerosis. Angina itself is not a disease but a symptom that reflects myocardial ischemia. It typically presents as pressure, squeezing, burning, or tightness in the chest, often triggered by exertion, stress, or after meals, and relieved by rest or nitroglycerin.

There are several types of angina, each with distinct clinical features:

  • Stable angina: Predictable and occurs with exertion or stress, relieved by rest or nitroglycerin.

  • Unstable angina: New-onset, worsening, or occurring at rest; part of the acute coronary syndrome (ACS) spectrum and requires urgent medical attention.

  • Variant (Prinzmetal’s) angina: Caused by coronary artery spasm, typically occurring at rest and often in younger patients.

  • Microvascular angina: Due to dysfunction of small coronary vessels rather than large epicardial arteries, more common in women.

Causes and Risk Factors

The main cause of angina is coronary artery disease, which reduces blood flow to the myocardium. Risk factors include:

  • Non-modifiable: age (older adults), male gender (though risk in women rises after menopause), family history of CAD.

  • Modifiable:

    • Hypertension

    • Hyperlipidemia (high LDL cholesterol, low HDL)

    • Diabetes mellitus

    • Smoking

    • Obesity and physical inactivity

    • Stress and unhealthy diet

Other contributing factors may include anemia, arrhythmias, or hyperthyroidism, which increase myocardial oxygen demand.

Symptoms

  • Chest pain or discomfort: often described as pressure, heaviness, or squeezing behind the breastbone.

  • Radiation: pain may spread to the shoulders, arms (particularly left), neck, jaw, or back.

  • Associated symptoms: shortness of breath, sweating, nausea, dizziness, and fatigue.

  • Stable angina: occurs predictably with activity, resolves with rest.

  • Unstable angina: pain occurs more frequently, with less exertion, or at rest.

Diagnosis

Diagnosis involves clinical assessment and investigations to confirm myocardial ischemia:

  • History and physical examination: nature of chest pain, risk factor assessment.

  • Electrocardiogram (ECG): may show ST depression or T-wave inversion during episodes.

  • Exercise stress testing: detects ischemia under exertion.

  • Echocardiography: evaluates cardiac function.

  • Coronary angiography: gold standard for diagnosing coronary artery narrowing.

  • Blood tests: lipid profile, fasting glucose, and cardiac enzymes (especially if ACS is suspected).

Treatment

The treatment of angina aims to relieve symptoms, prevent progression of CAD, and reduce the risk of myocardial infarction and death. Management includes lifestyle modifications, medications, and interventional procedures if necessary.

1. Lifestyle Modifications

  • Smoking cessation

  • Regular exercise (as tolerated)

  • Heart-healthy diet (low saturated fats, low salt, high fiber)

  • Weight management

  • Stress reduction

2. Pharmacological Treatment

a) Symptom relief (anti-anginal therapy):

  • Nitrates: cause vasodilation and improve blood supply to the heart.

    • Nitroglycerin: 0.3–0.6 mg sublingually as needed for acute attacks; long-acting forms (e.g., isosorbide mononitrate 20–60 mg orally once or twice daily) for prevention.

  • Beta-blockers: reduce heart rate and myocardial oxygen demand.

    • Metoprolol: 50–200 mg/day orally in divided doses.

    • Atenolol: 25–100 mg orally once daily.

  • Calcium channel blockers: relax coronary arteries and reduce cardiac workload, especially in variant angina.

    • Amlodipine: 5–10 mg orally once daily.

    • Diltiazem: 120–360 mg orally daily in divided doses or sustained-release formulation.

  • Ranolazine: reduces angina symptoms without affecting heart rate or blood pressure.

    • Ranolazine: 500–1000 mg orally twice daily.

b) Secondary prevention (reduce risk of MI and progression of CAD):

  • Antiplatelets:

    • Aspirin: 75–162 mg orally daily (mainstay of therapy).

    • Clopidogrel: 75 mg orally daily if aspirin is contraindicated or combined therapy is indicated.

  • Statins: lower cholesterol and stabilize plaques.

    • Atorvastatin: 10–80 mg orally once daily.

    • Rosuvastatin: 5–40 mg orally once daily.

  • ACE inhibitors/ARBs: improve survival in patients with CAD, diabetes, or hypertension.

    • Enalapril: 5–40 mg orally daily in divided doses.

    • Losartan: 50–100 mg orally daily.

3. Interventional and Surgical Options

  • Percutaneous coronary intervention (PCI): balloon angioplasty with or without stent placement to restore blood flow.

  • Coronary artery bypass grafting (CABG): surgical revascularization for severe or multivessel disease.

Complications

  • Acute myocardial infarction

  • Heart failure

  • Arrhythmias

  • Sudden cardiac death

Prevention

Preventive measures focus on addressing modifiable risk factors:

  • Control blood pressure, cholesterol, and blood sugar.

  • Adopt a Mediterranean or DASH-style diet.

  • Avoid smoking and excessive alcohol.

  • Regular physical activity (at least 150 minutes/week of moderate-intensity exercise).

  • Adherence to prescribed medications.





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