(USMLE topics, cardiology) Characteristics of various types of angina, pathology, diagnosis and treatment.
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Angina pectoris is chest pain/discomfort caused by reduced blood flow to the heart, in a condition known as myocardial ischemia.
Signs and symptoms: squeezing pain or heaviness in the chest, which may also spread to the neck, arms, shoulders and back; or in the stomach area after meals. Women are more likely to experience a burning sensation. Angina is not the same as heart attack. It is associated with transient ischemia without infraction. But it increases the risks for heart attacks.
Angina is caused by the narrowing of one or more coronary arteries that supply the heart. This can result from a fixed obstruction by cholesterol plaques, or a temporary constriction due to blood vessel spasms.
There are several types of angina.
Stable angina (effort angina), the most common form, is usually caused by a fixed obstruction, a plaque. Stable angina is predictable, with familiar pain patterns, and typically prompted by physical exertion, when the heart requires more oxygen than it can get from narrowed vessels. Factors that constrict blood vessels or increase blood pressure, such as emotional stress, cold temperatures or heavy meals, may also induce angina. Unstable angina may occur unexpectedly, even at rest, with a changed pattern from the usual stable angina. It is more severe, lasts longer, does not respond to rest or medications, and is often the sign that a plaque has ruptured or a clot has formed. Unstable angina is a medical emergency as it often precedes a heart attack.
Electrocardiograms (ECG/EKG) of patients with obstructive angina commonly show ST-segment depression during attacks. Diagnosis is confirmed with heart stress test. A number of patients with stable angina symptoms have normal coronary arteries on angiograms. These cases are now recognized as microvascular angina (Cardiac syndrome X), where the problem lies in tiny branches, and is therefore undetectable by angiography. Microvascular angina is much more common in women.
Variant angina (Prinzmetal angina) is caused by vascular spasms of coronary arteries. Variant angina is often severe, but responds well to medications. Diagnosis is by presence of ST-segment elevation during attacks, and provocative testing with drugs that induce coronary artery spasms.
Treatment of angina aims to relieve symptoms, reduce frequency of future anginas, but most importantly, reduce risks of heart attacks. Apart from lifestyle changes to modify risk factors, treatment options include a number of medications and surgical procedures.
Nitroglycerin, a potent vasodilator, is most effective for acute anginal attacks. Long-lasting nitrates, antiplatelet drugs (aspirin…), beta-blockers, and calcium channel blockers can be prescribed to prevent future anginas.
Revascularization surgical procedures include coronary angioplasty and coronary bypass.