Angina Pectoris

Angina is the term for a clinical syndrome with precordial discomfort or pressure in the chest area due to a temporary myocardial ischemia without infarction. It is typically triggered by exercise or psychological stress. At rest or with nitroglycerin sublingual symptoms subside. The diagnosis results from the symptoms, the ECG and from the imaging of the myocardium. Among the treatment options include antiplatelet drugs, nitrates, beta blockers, calcium channel blockers, ACE inhibitors, statins, coronary angioplasty or coronary bypass surgery.

(See also Overview of coronary heart disease.)

Angina is the term for a clinical syndrome with precordial discomfort or pressure in the chest area due to a temporary myocardial ischemia without infarction. It is typically triggered by exercise or psychological stress. At rest or with nitroglycerin sublingual symptoms subside. The diagnosis results from the symptoms, the ECG and from the imaging of the myocardium. Among the treatment options include antiplatelet drugs, nitrates, beta blockers, calcium channel blockers, ACE inhibitors, statins, coronary angioplasty or coronary bypass surgery. (See also Overview of coronary heart disease.) Etiology Angina pectoris occurs when the coronary arteries are no longer able to provide cardiac workload and the consequent myocardial oxygen consumption necessary amount of oxygen-rich blood available for. This may occur when the arteries are narrowed. The narrowing usually arises due to atherosclerosis of the coronary arteries, but also by a coronary spasm or but rarely, by a Koronarembolie. An acute coronary thrombosis may cause by a partial or temporary obstruction angina pectoris. In general, however, this causes an acute myocardial infarction (MI). Since the myocardial oxygen demand is determined mainly by the heart rate, systolic wall stress, and the contraction force, the narrowing of a coronary artery typically results in angina that occurs under physical stress and decreases at rest. In addition to physical stress cardiac work load may be increased by diseases such as hypertension, aortic stenosis, aortic valve insufficiency or hypertrophic cardiomyopathy. In such cases there may pectoris angina with or without atherosclerosis. These diseases can also reduce the relative myocardial perfusion, as the myocardial mass is increased (a decreased diastolic blood flow causing). A reduced oxygen supply such. As in severe anemia or hypoxia, can induce or enhance angina. Pathophysiology angina may be Stable Unstable With stable angina, the relationship between cardiac workload and oxygen demand and ischemia usually pectoris is relatively predictable. unstable angina is a clinically deteriorating angina (z. B. angina at rest or increasing frequency and / or intensity of episodes). The degree of arteriosclerotic narrowing of the coronary vessels is not completely fixed and varies with the normal fluctuations of the arterial tone that are found in all humans. Therefore angina rather occurs in the morning, when the vascular tone is relatively high. Also abnormal endothelial function may contribute to fluctuations in vascular tone. For example, due to a sudden increase of catecholamines in a damaged by atheromas endothelium vasoconstriction instead of a dilatation (normal reaction). When the myocardium becomes ischemic, the blood pH in the coronary sinus drops, there is a cellular potassium loss and a lactate accumulation. The ECG show changes and ventricular function (both systolic diastolic) deteriorates. Usually, the diastolic pressure in the left ventricle (LV) increases pectoris during an angina. Sometimes it happens while a pulmonary congestion and dyspnea. The exact mechanism by which causes ischemia symptoms is not clear. It is possible that stimulation of the nerve is involved by hypoxic metabolites. Symptoms and signs The symptoms of angina can be perceived in the chest than a vague, barely disturbing feeling of pressure or very quickly as a serious destruction strong feeling. It is rarely described as pain. The complaints are usually located below the sternum, but vary. The discomfort may radiate to the left shoulder, along the inside of the left arm, and even to his finger, right in the back, neck, jaw and teeth, and occasionally along the inside of the right arm. They can be felt in the area of ??the upper abdomen. The symptoms of angina are never above the ears or below the belly button. Atypical angina (z. B. with bloating, abdominal pain) may occur in some patients. These patients often describe symptoms that fit rather to indigestion. may even facilitate belching the discomfort. Other patients suffer from dyspnea due to the steep, reversible increase in left ventricular filling pressure, which is often associated with ischemia. Often, the symptoms of the patient are described inaccurate and it can be difficult to determine whether there is an angina, dyspnea, or both. Since ischemic symptoms lasting a minute or more, it rarely is in short, fleeting sensations to angina. Between the individual angina pectoris attacks and even during an attack of the physical findings of the patient can be normal. During the attack, however, the heart rate may increase modestly, often the blood pressure is elevated, the heart sounds become weaker and the heart’s impulse is blurred. There may be a paradoxical second heart sound, because the left ventricular ejection phase is extended during the ischemic attack. A fourth heart sound is widely used and a third heart sound can develop. A shrill or blowing – but not particularly loud – medium or spätsystolisches noise in the apex may be present if the ischemia leads to a local papillary muscle, which in turn causes mitral regurgitation. Angina is typically triggered by exercise or strong emotions, usually takes no longer than a few minutes and sounds in peace again. In general, the response to exercise is predictable. In some patients, exercise can be tolerated in a day, trigger an angina pectoris due to variations of the arterial tone the next however. The symptoms are particularly strong when after a meal, a physical effort or where the physical strain takes place on cold days. An angina attack can be triggered by running against the wind or on first contact with cold air after leaving a warm room. The severity of symptoms is often determined by the degree of physical stress, which leads to angina (see table: classification system of the Canadian Cardiovascular Society for angina). Classification system of the Canadian Cardiovascular Society angina class for activities that cause chest pain 1 Tedious, rapid or prolonged exertion None of the usual physical activities (eg. As walking, climbing stairs) 2 Fast walking walking uphill Fast climbing stairs Walking or climbing stairs after meals cold wind Emotional stress three go, even 1 or 2 blocks at the usual pace on level ground climbing stairs, even a staircase 4 Any physical activity Sometimes at rest occurring Adapted from Braunwald E, Antman EM, Beasley JW, et al: ACC / AHA Guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: A report of the American College of Cardiology / American Heart Association task Force on Practice Guidelines (Committee on the management of patients with unstable angina). Journal of American College of Cardiology 36: 970-1062, 2000. The number of seizures varies from several attacks per day to symptom-free intervals over weeks, months or years. Attacks can in frequency increase (crescendo angina) until it comes in a myocardial infarction or death, or gradually diminish or disappear when an adequate coronary collateral circulation develops when the ischemic area infarcted or if a failure or intermittent claudication arrives and physical activity limits. A nocturnal angina pectoris may occur if the intensity of a dream significant changes in respiration, pulse rate and blood pressure effects. The nocturnal angina may be a sign of a recurrent left ventricular failure, which corresponds to a nocturnal dyspnea. The position lying increases venous return, expands the myocardium and increases the wall stress, which increases the oxygen use. Angina decubitus is a form of angina, which occurs spontaneously during rest. It is accompanied by a moderate increase in heart rate and occasionally significantly higher blood pressure in general. Both effects lead to an increased oxygen demand. These increases may be the cause of angina at rest or the result of ischemia, which is caused by the rupture of a plaque and the formation of thrombi. If the angina is not relieved, the unmet myocardial oxygen demands increased further, creating a myocardial infarction is likely. Unstable angina Since the characteristics of angina in the individual patient are usually predictable, all changes (eg. As angina at rest, new onset or worsening angina angina) should be taken seriously, v. a. if the angina is severe (i. e. class 3 according to Canadian Cardiovascular Society). Such changes are referred to as unstable angina and require immediate investigation and Behandlung.Stumme ischemia patients with coronary heart disease (v. A. Patients with diabetes) may have ischemia without showing symptoms. The silent ischemia sometimes seen in transient asymptomatic ST-T-deviations which will be displayed in a stress test or a 24-h ECG. Radionukliduntersuchungen can sometimes documented asymptomatic myocardial ischemia during physical or mental exertion. The silent ischemia may be associated with angina pectoris, but occur at different times. The prognosis depends on the severity of coronary artery disease. Diagnosis Typical symptoms ECG stress testing with ECG or imaging (echocardiography or nuclear medicine) coronary angiography for significant symptoms or positive stress test Suspected angina exists when it comes to typical chest discomfort that occur during exercise and subside at rest. The presence of major risk factors for coronary heart disease (CHD) in the past increases the weight of the symptoms reported. Patients in whom the chest discomfort> 20 min persist or occur at rest, the syncope or heart failure have to be examined in terms of an acute coronary syndrome. Chest discomfort can also by gastrointestinal disorders (eg. B. reflux, esophageal spasm, indigestion, cholecystolithiasis) caused by a costochondritis, anxiety, panic disorder, or hyperventilation. Other heart diseases (eg. As aortic dissection, pericarditis, mitral valve prolapse, supraventricular tachycardia or atrial fibrillation) can cause chest pain, even if the coronary circulation is not affected. An ECG is always used. More specific tests are stress tests with ECG control, or representation of the myocardium (for. Example, echocardiography, radionuclide scintigraphy, MRI) and angiography. First, non-invasive tests are considered. In typical ECG stress symptoms, an ECG is indicated. Since angina at rest subsides quickly, an ECG can rarely be carried out during an event, except for a stress test. Is an ECG performed during an event, reversible ischemic changes show up with great probability: T wave is discordant to the QRS vector, ST-segment depression (typical), ST-segment elevation, decrease in R-wave height, intraventricular or in the limbs localized conduction abnormalities and arrhythmias (ventricular premature beats usually). Between the attacks the ECG (and usually left ventricular function) normal in 30% of patients with typical angina pectoris history and even in those with an extensive three-vessel disease alone. In the remaining 70% of the ECG is evidence of a previous infarcts, to hypertrophy or non-specific ST-segment and T-wave (ST-T) abnormalities. A pathological resting ECG diagnosis alone can not secure yet ausschließen.Stresstests stress tests are necessary to confirm the diagnosis, to assess the severity of the disease and to determine appropriate fitness programs for the patient. The tests help assess the patient’s prognosis. If the clinical or diagnostic work is unstable angina, early stress tests are contraindicated. In a CHD the exercise stress and the representation of myocardial perfusion using single photon emission CT (SPECT) or positron emission tomography (PET) provide the most accurate results. These testing procedures are more expensive than a simple exercise ECG. If a patient has a normal ECG findings at rest and is strain capable of producing a stress test is carried out. In men with chest pain, when the cause of angina pectoris is adopted, the stress ECG has a specificity of 70% and a sensitivity of 90%. The sensitivity is similar for women who specificity, however, especially in women <55 years low (<70%). Women, however, have often a pathological ECG (vs. 32% 23%) than men with CHD. Even if the sensitivity is relatively high, it may be that a severe coronary heart disease (even a left main disease, or a three-vessel disease) in Stress ECG is not recognizable. In patients with atypical symptoms and a negative exercise ECG angina and coronary heart disease are usually excluded. A positive result may indicate coronary ischemia or not and therefore requires further study is needed. In a pathological resting ECG false positive ST segment changes in the stress test are common. Therefore, here a stress test showing the myocardium is recommended. The stress test may be carried out under physical stress or drug-induced (with dobutamine or Dipyridamolinfusion z. B.). The choice of imaging technique depends on what devices are available and what experience have doctors. By way of illustration process the function of the LV and its response to stress can be determined, to identify ischemic areas, infarctions and functional tissue and the localization and extent of vulnerable myocardium are determined. By means of an exercise stress, it is possible to ischemia-induced Mitralklappeninsuffizienz festzustellen.Angiographie Coronary angiography is the standard method for the diagnosis of CHD. However, it is not always necessary to confirm the diagnosis. It is indicated mainly for localization of coronary lesions and to assess its severity if revascularization is drawn (by percutaneous coronary intervention [PCI] or coronary bypass surgery [CABG]) into consideration. Angiography may also be displayed when a precise knowledge of the anatomy of the coronary arteries is necessary in order to advise the patient with regard to his work and his life (eg. As the task of the profession or sports activities). Although angiographic findings show the hemodynamic significance of coronary lesions not directly, the obstruction is significant, assumed to be physiologically when luminal diameter is reduced by> 70%. Such narrowing correlates well with the finding of angina pectoris, if not yet added is a spasm or a thrombosis. With the help of the intravascular ultrasound (IVUS) can be represented the structure of the coronary vessels. During angiography, an ultrasonic probe at the tip of a catheter is introduced into the coronary arteries. This allows more information about the anatomy of the coronary arteries can be recovered as by other methods. An IVUS study is indicated when the nature of the lesions is unclear or if the apparent severity of the disease does not match the severity of the symptoms. This process is suitable for angioplasty and to ensure the optimal placement of a stent. Guidewires with pressure or flow sensors can be used to assess blood flow through stenosis. The blood flow is expressed as fractional flow reserve (FFR), which expressed the ratio of the maximum flow through the stenotic area of ??the normal maximum flow. These blood flow measurements are particularly useful when the need for angioplasty or CABG in patients with lesions questionable severity (40-70% stenosis) is evaluated. A FFR of 1.0 is considered normal while a FFR associated of <0.75-0.8 with myocardial ischemia. Lesions with an FFR> 0.8 have a lower likelihood of stent implantation to profitieren.Bildgebung Electron beam CT can detect the calcium content in coronary plaques. The calcium score (1-100) is proportional to the risk of subsequent coronary events in approximately. However, since calcium can be in the absence of significant stenosis, the result does not correlate highly with the need for angioplasty or CABG. Therefore, the American Heart Association recommends that screening with electron beam CT is performed only in selected groups of patients and that it is most valuable when it is combined with historical and clinical data to estimate the risk of death and MI nonfataler. These groups may include asymptomatic patients with a mean Framingham 10-year risk estimate of 10-20% and symptomatic patients with ambiguous results in stress tests. Electron tomography is particularly useful to exclude significant coronary artery disease in patients who are presented in the emergency room with atypical symptoms normal troponin levels and a low probability hemodynamically significant coronary artery disease. In these patients ambulatory noninvasive tests can be performed. The reconstructed to a multi-Zeiler cardiac CT virtual coronary angiography can accurately identify coronary stenosis and has a number of advantages. The test is non-invasive coronary stenosis may, with high accuracy, grasp the stent or bypass patency showing cardiac and coronary venous anatomy and assess the calcified and non-calcified plaque burden. However, the radiation exposure is significant and the test is for patients with a heart rate> 65 beats / min, those not suitable with an irregular heartbeat and pregnant women. Patients must also be able to hold their breath 3 to 4 times during the study for 15 to 20 seconds. Developing indications for MDRCT coronary angiography include asymptomatic high-risk patients or patients with atypical or typical angina who have ambiguous results in the stress test, can not carry the load test or have to undergo major cardiac surgery patients undergoing invasive coronary angiography one of the could not locate major coronary artery or bypass graft. Cardiac MRI has become irreplaceable in the assessment of many cardiac or major vascular anomalies. It can be used to CHD by several techniques vs direct visualization of coronary stenosis, an assessment of blood flow in the coronary arteries, an evaluation of myocardial perfusion and myocardial metabolism, an evaluation of wall motion abnormalities during stress and an assessment of the infarct areas , allow vital areas of the myocardium. Current indications for cardiac MRI include an evaluation of cardiac structure and function, an assessment of myocardial viability and possibly the diagnosis and risk assessment of patients with either known or suspected coronary artery disease. Prognosis The main complications are unstable angina pectoris, myocardial infarction and sudden death due to arrhythmias. The annual mortality rate is in patients with angina without history of myocardial infarction, a normal resting ECG and normal blood pressure at about 1.4%. In women with CHD, however, the prognosis is slightly worse. The mortality rate is existence of systolic hypertension in approximately 7.5%, with a pathological ECG at 8.4% and in the presence of both at 12%. A type 2 diabetes approximately doubles the mortality rate of all findings. With age, more and more difficult pektanginöser symptoms, the presence of anatomical lesions and poor ventricular function, the prognosis is worse. Lesions of the main trunk of the left coronary artery or the proximal LAD associated with a particularly high risk. Although the prognosis correlates with the number of coronary arteries affected and the severity, the prognosis for patients with stable angina pectoris is surprisingly good, even with a three-vessel disease when ventricular function is normal. Treatment modification of risk factors (smoking, blood pressure, lipids) antiplatelet agents (aspirin and sometimes clopidogrel, prasugrel or ticagrelor) beta blockers nitroglycerin and calcium channel blockers for symptom control, ACE inhibitors and statins revascularization if symptoms persist despite medical treatment, this is the extent possible, are the risk factors modified (atherosclerosis: treatment). Smokers should quit smoking. After a period of ?2 years without smoking, the risk of myocardial infarction equivalent to that of those who never smoked. Hypertension should be treated with care, as even slightly excessive blood pressure increase the cardiac workload. Already a decrease in body weight alone reduced often pectoris severity of angina. Sometimes the treatment of mild left ventricular insufficiency leads to relief of symptoms pektanginösen. Paradoxically worsen digitalis occasionally pectoris symptoms of angina. This occurs probably as a result of the increased force of contraction of the myocardium, which leads to an increased oxygen requirement, or because of the increased vascular tone, or a combination of both. A radical reduction of total cholesterol and low-density lipoprotein (LDL) cholesterol (dietary and, depending on necessity, medication) to slow the progression of coronary artery disease, can cause a regression of individual lesions (dyslipidemia: treatment), and endothelial function and improve the response of the coronary arteries on load. A physical exercise program in which the emphasis is placed on walks, often improves the well-being, reduces the risk of an acute ischemic event and improves exercise capacity. Drugs main objectives of the treatment of angina or decrease to relieving acute symptoms preventing ischemia prevention of future ischemic events For the treatment of an acute attack is nitroglycerin sublingual the most effective drug. (See table: drugs for coronary heart disease *) For the prevention of ischemia, all patients should take a diagnosed coronary heart disease or at high risk of developing coronary heart disease, a daily antiplatelet agents. Most patients are given beta-blockers, if not a contraindication or intolerance exists. In some patients, prevention of symptoms associated with calcium channel blockers or long-acting nitrates is required. Antiplatelet drugs prevent the aggregation of platelets. Aspirin binds irreversibly to platelets and inhibits the cyclooxygenase and thus the platelet aggregation. Other antiplatelet drugs (eg. As clopidogrel and prasugrel ticagrelor) block the adenosine diphosphate-induced platelet aggregation. These drugs can reduce the risk of ischemic events (MI, sudden death), but the drugs are most effective when given together. Patients who can not tolerate one of the drugs should be given to the other alone. Beta blockers relieve symptoms, prevent myocardial infarction and sudden cardiac death better than other drugs. Beta blockers inhibit the sympathetic activation of the heart, reduce the systolic blood pressure, heart rate, contractility and cardiac output, thereby reducing the O2 demand of the myocardium and increase the ability to exercise. Beta blockers also raise the threshold for ventricular fibrillation. Most patients tolerate these medications well. Many beta blockers are available and effective. The dose is increased as long as necessary, as long as no bradycardia or other side effects occur. Patients who do not tolerate the beta-blockers are treated with a calcium antagonist with a negative chronotropic effect (eg. B. diltiazem or Verapamil). Those at risk of, beta-blockers intolerance (z. B. patients with asthma) can tentatively receive a cardioselective beta-blocker (eg. B. bisoprolol), possibly with pulmonary function tests before and after administration of the drug, to detect a drug-induced bronchospasm. Nitroglycerinist a potent smooth muscle relaxant and vasodilator. Its main sites of action are the peripheral vascular system, especially the venous system, the capacity of vessels and the coronary vessels. Even strong atherosclerotic vessels can be extended in sections that are not affected by atheroma. Nitroglycerin lowers the systolic blood pressure, dilated veins, the entire system and thus reduces myocardial wall stress, which is one of the main factors in myocardial oxygen demand. Sublingual nitroglycerin is given for acute complaints and preventively against physical stress. The symptoms can be significantly after the first 1.5 to 3 minutes, asymptomatic patients are after about 5 minutes. The effect lasts up to 30 minutes. The dose may be each 4-5 minutes repeated up to three times if the relief is incomplete. Patients should always carry nitroglycerin tablets or aerosol spray with them to make immediate use of it in an incipient attack. Patients should keep the tablets in a tightly sealed, opaque glass container, so that the effectiveness is not lost. Since the substance decomposes rapidly, you should consider more frequent purchase of small amounts. Langwirksame Nitrate (oral oder transdermal) werden dann eingesetzt, wenn die Symptome trotz maximaler Dosierung der Betablocker andauern. Tritt eine Angina pectoris zu einer vorhersehbaren Tageszeit auf, kann ein Nitrat gegeben werden, um diese Zeiten abzudecken. Zu den Nitraten oraler Applikationsform gehören Isosorbiddinitrat und Isosorbidmononitrat (aktiver Metabolit des Dinitrats). Sie sind innerhalb von 1–2 h wirksam und ihre Wirkung hält 4–6 h an. Isosorbidmononitratpräparate mit kontinuierlicher Wirkstofffreisetzung scheinen über den ganzen Tag wirksam zu sein. Bei der transdermalen Anwendung haben die Nitroglycerinpflaster weitgehend die Nitroglycerinsalben ersetzt, da die Anwendung Letzterer eher lästig und unbequem ist. Nitroglycerinpflaster haben aufgrund der langsamen Freigabe des Wirkstoffes einen langanhaltenden therapeutischen Effekt. Die körperliche Belastbarkeit verbessert sich 4 h nach der Applikation des Pflasters, nimmt jedoch nach 18–24 h wieder ab. Eine Nitrattoleranz kann v. a. dann auftreten, wenn die Plasmakonzentration des Wirkstoffes konstant gehalten wird. Da das Risiko eines Myokardinfarktes in den frühen Morgenstunden am höchsten ist, eignet sich eine Nitratpause am Nachmittag oder frühen Abend, es sei denn, die Angina pectoris tritt für gewöhnlich zu dieser Zeit auf. Für Nitroglycerin scheint eine Pause von 8–10 h ausreichend zu sein. Bei Isosorbiden kann eine Pause von 12 h erforderlich sein. Wenn sie 1-mal täglich gegeben werden, scheinen Isosorbidmononitrate mit einer kontinuierlichen Wirkstofffreisetzung keine Toleranz auszulösen. Kalziumantagonisten können dann eingesetzt werden, wenn die Symptomatik trotz der Gabe von Nitraten fortbesteht oder wenn Nitrate vom Patienten nicht toleriert werden. Kalziumantagonisten sind v

Health Life Media Team

Leave a Reply