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srimathi sundaravalli
memorial school
chromepet, Chennai-63
Topic: angina pectoris
By:
v.illakiya
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I wish to express my deep gratitude and my heartfelt thanks to my principal MRS.
VIJAYALAKSHMI who is also my biology teacher for her excellent guidance, support
and encouragement without which the successful completion of this project wouldn’t
have been possible.
It also gives me great pleasure in expressing my gratitude for the facilities that were
provided by the school.
I also thank my parents for their constant support and their painstaking efforts and my
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1. Introduction
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2. Main Symptoms
4
3. Major Types
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4. Major Risk Factors
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5. A Major Cause: Coronary Artery Disease 10
6. Why Is It Important To Establish Diagnosis?10
7. Diagnosis
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8. Treatment
15
9. Angioplasty And Coronary Artery Bypass 18
Surgery
10. New Treatments
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11. Living with Angina: A Case Study
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12. Conclusion
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INTRODUCTION
Angina pectoris, commonly known as angina, is chest paindue to ischemia (a lack
of blood, thus a lack of oxygen supply and waste removal) of the heart muscle, generally due
to obstruction or spasm of the coronary arteries (the heart's blood vessels). Coronary artery
disease, the main cause of angina, is due to atherosclerosis of the coronary arteries
There is a weak relationship between severity of pain and degree of oxygen
deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a heart
attack, and a heart attack can occur without pain).
Worsening angina attacks, sudden-onset angina at rest, and angina lasting more than
15 minutes are symptoms of unstable angina (usually grouped with similar conditions as
the acute coronary syndrome). As these may herald myocardial infarction (a heart attack),
they require urgent medical attention and are generally treated as a presumed heart attack.
MAIN SYMPTOMS
Angina is chest discomfort that occurs when there is decreased blood oxygen supply to an
area of the heart muscle. In most cases, the lack of blood supply is due to a narrowing of the
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Angina is usually felt as:
pressure,
heaviness,
tightening,
squeezing, or
Aching across the chest, particularly behind the breastbone.
This pain often radiates to the neck, jaw, arms, back, or even the teeth.
Patients may also suffer:
indigestion, heartburn, weakness, sweating, nausea, cramping, and Shortness of breath.
Angina usually occurs during exertion, severe emotional stress, or after a heavy meal,
when the heart muscle demands more blood oxygen than the narrowed coronary arteries can
deliver. Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing
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pressure. Both rest and nitroglycerin decrease the heart muscles demand for oxygen, relieving
angina.
THE MAJOR TYPES:
1. Stable angina2. Unstable angina
3. Microvascular angina
1. Stable Angina:
Stable angina is the most common type of angina, and what most people mean when
they refer to angina. People with stable angina have angina symptoms on a regular basis and
the symptoms are somewhat predictable (for example, walking up a flight of steps causes’
chest pain). For most patients, symptoms occur during exertion and commonly last less than
five minutes. They are relieved by rest or medication, such as nitroglycerin under the tongue.
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2. Unstable Angina:
Unstable angina is less common but more serious. The symptoms are more severe and less
predictable than the pattern of stable angina. Pain is more frequent, lasts longer, occurs at
rest, and is not relieved by nitroglycerin under the tongue (or the patient needs to use more
nitroglycerin than usual). Unstable angina is not the same as a heart attack, but warrants an
immediate visit to your physician or hospital emergency department as further cardiac testing
is urgently needed. Unstable angina is often a precursor to a heart attack.
3. Microvascular Angina:
Microvascular Angina or Angina Syndrome X is characterized by angina-like chest pain, but
has different causes. The cause of Microvascular Angina is unknown, but it appears to be the
result of poor function in the tiny blood vessels of the heart, arms and legs. Since
Microvascular angina isn't characterized by arterial blockages, it's harder to recognize and
diagnose, but its prognosis is excellent.
MAJOR RISK FACTORS:
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Cigarette smoking
Diabetes mellitus (DM)
Dyslipidemia
Family History of premature Cardiovascular Disease (men <55 years, female
<65 years old)
Hypertension (HTN)
Kidney disease (microalbuminuria or GFR<60 mL/min)
Obesity (BMI ≥ 30 kg/m2)
Physical inactivity
Conditions that exacerbate or provoke angina
Medications
vasodilators
excessive thyroid replacement
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polycythemia which thickens the blood causing it to slow its flow through the heart
muscle
One study found that smokers with coronary artery disease had a significantly increased
level of sympathetic nerve activity when compared to those without. This is in addition to
increases in blood pressure, heart rate and peripheral vascular resistance associated with
nicotine which may lead to recurrent angina attacks. Additionally, CDC reports that the
risk of CHD (Coronary heart disease), stroke, and PVD (Peripheral vascular disease) is
reduced within 1–2 years of smoking cessation. In another study, it was found that after
one year, the prevalence of angina in smoking men under 60 after an initial attack was
40% less in those who had quit smoking compared to those who continued. Studies have
found that there are short term and long term benefits to smoking cessation.
Other medical problems
profound anemia
uncontrolled HTN
hyperthyroidism
hypoxemia
Other cardiac problems
tachyarrhythmia
bradyarrhythmia
valvular heart disease
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A Major Cause: Coronary Artery Disease
Coronary arteries supply oxygenated blood to the heart muscle. Coronary artery disease
develops as cholesterol is deposited in the artery wall, causing the formation of a hard, thick
substance called cholesterol plaque. The accumulation of cholesterol plaque over time causes
narrowing of the coronary arteries, a process called arteriosclerosis. Arteriosclerosis can be
accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. When
coronary arteries become narrowed by more than 50% to 70%, they may no longer be able to
meet the increased blood oxygen demand by the heart muscle during exercise or stress. Lack
of oxygen to the heart muscle causes chest pain (angina)
WHY IS IT IMPORTANT TO ESTABLISH
DIAGNOSIS?
Angina is usually a warning sign of the presence of significant coronary artery disease.
Patients with angina are at risk of developing a heart attack (myocardial infarction). A heart
attack is the death of heart muscle precipitated by the complete blockage of a diseased
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During angina, the lack of oxygen (ischemia) to the heart muscle is temporary and reversible.
The lack of oxygen to the heart muscle resolves and the chest pain disappears when the
patient rests or takes nitroglycerin. In contrast, the muscle damage in a heart attack may be
permanent, if there is a delay in obtaining emergency treatment. The dead muscle turns into
scar tissue when healed. A scarred heart that results from a heart attack cannot pump blood as
efficiently as a normal heart, and can lead to heart failure.
Many patients with significant coronary artery disease have no symptoms at all, even though
they clearly lack adequate blood and oxygen supply to the heart muscle. These patients have
"silent" angina. They have the same risk of heart attack as those with symptoms of angina.
DIAGNOSIS
The electrocardiogram (EKG or ECG) is a recording of the electrical activity of the heart
muscle, and can detect heart muscle which is in need of oxygen. The EKG is useful in
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1. Exercise stress test
In patients with a normal resting EKG, exercise treadmill or bicycle testing can be useful
screening tools for coronary artery disease. During an exercise stress test (also referred to as
stress test, exercise electrocardiogram, graded exercise treadmill test, or stress ECG), EKG
recordings of the heart are performed continuously as the patient walks on a treadmill or
pedals on a stationary bike at increasing levels of difficulty. The occurrence of chest pain
during exercise can be correlated with changes on the EKG, which demonstrates the lack of
oxygen to the heart muscle. When the patient rests, the angina and the changes on the EKG
which indicate lack of oxygen to the heart can both disappear. The accuracy of exercise stress
tests in the diagnosis of significant coronary artery disease is 60% to 70%. If the exercise
stress test does not show signs of coronary artery disease, a nuclear agent (thallium or
cardiolyte) can be given intravenously during the test. The addition of thallium or cardiolyte
allows nuclear imaging of blood flow to different regions of the heart, using an external
camera. A reduced blood flow in an area of the heart during exercise, with normal blood flow
to the area at rest, signifies significant artery narrowing in that region of the heart.
2. Stress echocardiography
Stress echocardiography combines echocardiography (ultrasound imaging of the heart
muscle) with exercise stress testing. Like the exercise thallium test, stress echocardiography
is more accurate than an exercise stress test in detecting coronary artery disease. When a
coronary artery is significantly narrowed, the heart muscle supplied by this artery does not
contract as well as the rest of the heart muscle during exercise. Abnormalities in muscle
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stress tests are both about 85% to 90% accurate in detecting significant coronary artery
disease.
When a patient cannot undergo exercise stress test because of neurological or orthopedic
difficulties, medications can be injected intravenously to simulate the stress on the heart
normally brought on by exercise. Heart imaging can be performed with a nuclear camera or
echocardiography.
3. Cardiac catheterization
Cardiac catheterization with angiography (coronary arteriography) is a technique that allows
X-ray pictures to be taken of the coronary arteries. It is the most accurate test to detect
coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under X-ray
guidance to the openings of the coronary arteries. Iodine contrast "dye" is injected into the
arteries while an X-ray video is recorded. Coronary arteriography gives the doctor a picture
of the location and severity of coronary artery disease. This information can be important in
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4. CT coronary angiogram
CT coronary angiography is procedure that uses an intravenous dye that contains iodine, and
CT scanning to image the coronary arteries. While the use of catheters is not necessary (this
procedure is considered "noninvasive"), there are still some risks involved, including:
patients allergic to iodine;
patients with abnormal kidney function; and
Radiation exposure which is similar to, or greater than, that received with a
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This is generally a very safe test for most people. It can be a useful tool in the diagnosis of
coronary artery disease in patients:
at high risk for developing coronary disease (cigarette smokers, those with genetic
risk, high cholesterol levels, hypertension, or diabetes);
who have unclear results with exercise stress tests or other testing; or
Who have symptoms suspicious of coronary disease.
TREATMENT
The most specific medicine to treat angina is nitroglycerin. It is a
potent vasodilator that makes more oxygen available to the heart muscle.
Beta-blockers and calcium channel Beta-blockers act to decrease the heart's workload, and thus its
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as Sildenafil (Viagra), Tadalafil (Cialis), or Vardenafil (Levitra) have been taken within the
previous 12 hours as the combination of the two could cause a serious drop in blood pressure.
Treatments are balloon angioplasty, in which the balloon is inserted at the end of
a catheter and inflated to widen the arterial lumen. Stents to maintain the arterial widening are
often used at the same time. Surgery involves bypassing constricted arteries with venous
grafts. This is much more invasive than angioplasty.
The main goals of treatment in angina pectoris are relief of symptoms, slowing progression of
the disease, and reduction of future events, especially heart attacks and, of course, death. Beta
blockers (e.g., carvedilol, propranolol, atenolol) have a large body of evidence in morbidity
and mortality benefits (fewer symptoms, less disability and longer life) and short-acting
nitroglycerin medications have been used since 1879 for symptomatic relief of
angina. Calcium channel blockers (such as nifedipine (Adalat) and amlodipine), isosorbide
mononitrate and nicorandil are vasodilators commonly used in chronic stable angina.A new
therapeutic class, called if inhibitor, has recently been made available: ivabradine provides
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inhibitors are also vasodilators with both symptomatic and prognostic benefit and,
lastly, statinsare the most frequently used lipid/cholesterol modifiers which probably also
stabilize existing atheromatous plaque[.Low-dose aspirin decreases the risk of heart attack in
patients with chronic stable angina, and was previously part of standard treatment; however,
it has since been discovered that the increase in haemorrhagic stroke and gastrointestinal
bleeding offsets this gain so they are no longer advised unless the risk of myocardial
infarction is very high.
Exercise is also a very good long term treatment for the angina (but only particular regimens -
gentle and sustained exercise rather than intense short bursts), probably working by complex
mechanisms such as improving blood pressure and promoting coronary artery
collateralisation.
Identifying and treating risk factors for further coronary heart disease is a priority in patients
with angina. This means testing for elevated cholesterol and other fats in the blood, diabetes
and hypertension (high blood pressure), encouraging stopping smoking and weight
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The calcium channel blocker nifedipine prolongs cardiovascular event- and procedure-free
survival in patients with coronary artery disease. New overt heart failures were reduced by
29% compared to placebo; however, the mortality rate difference between the two groups
was statistically insignificant.
The fatty acid oxidation inhibitor mildronate is a clinically-used anti-ischemic drug for the
treatment of angina and myocardial infarction. Mildronate shifts the myocardial energy
metabolism from fatty acid oxidation to the more oxygen sparing glucose oxidation under
ischemic conditions, by inhibiting enzymes in the carnitine biosynthesis pathway,.
including gamma-butyrobetaine dioxygenase. Mildronate also inhibits carnitine
acetyltransferase and therefore acts as a myocardial energy metabolism regulator.
ANGIOPLASTY AND CORONARY ARTERY
BYPASS SURGERY
When patients continue to have angina despite maximally tolerated combinations of
nitroglycerin medications, beta blockers, and calcium channel blockers, cardiac
catheterization with coronary arteriography is indicated. Depending on the location and
severity of the disease in the coronary arteries, patients can be referred for balloon
angioplasty (percutaneous transluminal coronary angioplasty or PTCA with or without stents)
or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.
NEW TREATMENTS
Coronary arteries may become narrow again (restenosis) after angioplasty, causing recurrent
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deploying stents to keep the arteries open. Drug-eluting stents are able to further reduce the
rate of artery restenosis by giving off a chemical that prevents scar formation tissue that could
block the artery.
LIVING WITH ANGINA: A CASE STUDY
Four years ago, when he was in his late 50s, Geoff began to feel breathless and tight-chested on his daily walk to work. “It was just over a mile and I enjoyed the exercise, particularly in
the nicer weather but in the spring of 2005, I just wasn’t feeling right,” he remembers. After a
few days of discomfort, which wore off as soon as he sat down at his desk in the council
offices where he worked, Geoff decided to see his doctor. “I actually thought I had a chest infection,” says Geoff.
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Angina is diagnosed
Geoff’s doctor knew as soon as he listened to Geoff’s chest that he didn’t have any signs of
an infection, but something was clearly wrong. He suspected that Geoff was experiencing the
symptoms of angina, which seemed to be fairly mild, but definitely needed checking out.
“I was booked in at the local hospital the following week to have an ECG and the practice
nurse took what seemed to be loads of blood to be sent away for testing. My blood count,
blood lipid levels, cholesterol level and the quantity of cardiac enzymes in my system were
all checked. While I was at the hospital for the ECG, they also did an ultrasound scan of my
heart and two weeks later I also had an angiogram,” explains Geoff.
Until the test results came through, Geoff was told to rest if his chest began to feel tight and to call for help if he experienced any severe chest pain. “Things didn’t really get any worse,
luckily, and I began to think it was all going to be a big fuss about nothing. However, when I
went back, the GP confirmed that I definitely had angina – one of my coronary arteries was 30% blocked, the other 40% and one was nearly 70% blocked. I began to get very worried,”
admits Geoff.
Treating Angina
Geoff was told about the various treatment options for angina and was told that, eventually,
he might have to have a heart bypass operation. He was immediately started on daily aspirin
treatment to thin his blood and prevent him having a heart attack if a blood clot got caught in the most narrowed coronary artery. “I was also given a drug called glyceryl trinitrate (GTN),
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GTN, taken during an angina attack, reduces the pain by acting on the coronary arteries to
make them relax so that blood can flow through them more easily.
A Bad Angina Attack
Geoff was also advised to take better care of his own health – he smoked 20 cigarettes a day
and made a great effort to give up. “I was less successful with my diet – I was also supposed
to lose some weight and eat a low fat diet but, with the stress of not smoking and the worry, I failed miserably,” says Geoff.
About three months later though, Geoff received a big wake up call that gave him fresh encouragement to improve his health. “I was rushing, late for work and on the way there I
had an unbelievable pain in the middle of my chest and to the left, with sharp and aching
pains all down my left arm. I half collapsed and a passing motorist stopped and called an ambulance and I ended up in A&E having another ECG,” says Geoff.
At first, the medical staff were concerned that Geoff had actually suffered a heart attack but
tests showed that there was no heart damage. Although one of this arteries was still almost
70% blocked, the tests did reveal that the blockages in the other two arteries had got worse
since his previous tests – all three arteries were now more than 50% blocked.
“I was given some longer-acting nitrates, which did help but I was constantly terrified that I
was going to have a heart attack. I was supposed to be avoiding stress, but my illness was stressing me out more than anything,” says Geoff.
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Surgery in 2007
At the end of 2007, after living with angina for over two years, Geoff went into hospital to
have a coronary artery bypass graft – a triple one – to replace all three of his blocked coronary arteries with healthy blood vessels from his legs. “It was a very scary experience but
I was surprised at how quickly I felt better, once I had recovered from the operation. I now no
longer have angina attacks – not only did I live with angina, I have survived it,” he says
triumphantly.
CONCLUSION
Angina pectoris is a chest pain caused by decrease oxygen supply to the heart muscle .ECG
,stress test and blood test are important in the diagnosis of angina .It is managed with rest,
medication and surgery.
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