Angina refers to the pain arising from lack of adequate blood
supply to the heart muscle. Typically, it is a crushing pain behind the
breastbone in the center of the chest, brought on by exertion and relieved by
rest. It may at times radiate to or arise in the left arm, neck, jaw, left
chest, or back. It is frequently accompanied by sweating, palpitations of the
heart, and generally lasts a matter of minutes. Similar pain syndromes may be
caused by other diseases, including esophagitis, gall bladder disease,
ulcers, and others.
Diagnosis of angina begins with the recognition of the consistent symptoms.
Often an exercise test with radioactive thallium is performed if the diagnosis
is in question, and sometimes even a cardiac catheterization is done if the
outcome is felt necessary to make management decisions. This is a complex
area which requires careful judgment by physician and patient.
Angina is a manifestation of coronary artery disease, the same disease
leading to heart attacks. Coronary artery diseas refers to those syndromes
caused by blockage to the flow of blood in those arteries supplying the heart
muscle itself, i.e., the coronary arteries. Like any other organ, the heart
requires a steady flow of oxygen and nutrients to provide energy for
rmovement, and to maintain the delicate balance of chemicals which allow for
the careful electrical rhythm control of the heart beat. Unlike some other
organs, the heart can survive only a matter of minutes without these
nutrients, and the rest of the body can survive only minutes without the
heart-thus the critical nature of these syndromes.
Causes of blockage range from congenital tissue strands within or over the
arteries to spasms of the muscular coat of the arteries themselves. By far
the most common cause, however, is the deposition of plaques of cholesterol,
platelets and other substances within the arterial walls. Sometimes the
buildup is very gradual, but in other cases the buildup is suddenly increased
as a chunk of matter breaks off and suddenly blocks the already narrowed
Certain factors seem to favor the buildup of these plaques. A strong family
history of heart attacks is a definite risk factor, reflecting some metabolic
derangement in either cholesterol handling or some other factor. Being male,
for reasons probably related to the protective effects of some female
hormones, is also a relative risk. Cigarette smoking and high blood pressure
are definite risks, both reversible in most cases. Risk also increases with
age. Elevated blood cholesterol levels (both total and low density types) are
risks, whereas the high density cholesterol level is a risk only if it is
reduced. Possible, but less well-defined factors include certain intense and
hostile or time-pressured personality types (so-called type A), inactive
lifestyle, and high cholesterol diets.
Medications are increasingly effective for symptom control, as well as
prevention of complications. The oldest and most common agents are the
nitrates, derivatives of nitroglycerine. They include nitroglycerine,
isosorbide, and similar agents. Newer forms include long acting oral agents,
plus skin patches which release a small amount through the skin into the
bloodstream over a full day. They act by reducing the burden of blood
returning to the heart from the veins and also by dilating the coronary
arteries themselves. Nitrates are highly effective for relief and prevention
of angina, and sometimes for limiting the size of a heart attack. Used both
for treatment of symptoms as well as prevention of anticipated symptoms,
nitrates are considered by many to be the mainstay of medical therapy for
The second group of drugs are called "beta blockers" for their
ability to block the activity of the beta receptors of the nervous system.
These receptors cause actions such as blood pressure elevation, rapid heart
rate, and forceful heart contractions. When these actions are reduced, the
heart needs less blood, and thus angina may be reduced.
The newest group of drugs for angina is called the calcium channel blockers.
Calcium channels refer to the areas of the membranes of heart and other cells
where calcium flows in and out, reacting with other chemicals to modulate the
force and rate of contractions. In the heart, they can reduce the force and
rate of contractions and electrical excitability, thereby having a calming
effect on the heart. Although their final place in heart disease remains to
be seen, they promise to play an increasingly important role.
When medications are unsuccessful, or if there is concern about an impending
or potential heart attack, coronary bypass surgery is highly successful in
reducing symptoms. Whether or not it prolongs survival is questionable for
Angina which is new or somehow different from previous episodes in any way is
termed unstable angina, is a medical emergency, and requires urgent
attention. Research is active, and careful medical follow-up is
important.mergency, and requires urgent attention. Research is active, and
careful medical follow-up is important.