Ishaemic heart disease is a major cause of death in many countries including Anguilla. The most common clinical manifestations of ishaemic heart disease are myocardial infarction, sudden death and angina pectoris.

What is angina pectoris?
Angina pectoris is a clinical syndrome resulting from transient myocardial ischaemia. Patients commonly decline to apply the word pain to their chest symptoms. They may use words such as heaviness, pressure, tightness, choking, or squeezing. The typical chest pain or discomfort is usually retrosternal but may radiate to, or be confined to, the jaw, throat, shoulder, back, or the left (or less frequently the right) arm or wrist. The pain of angina usually lasts from 1 to 15 minutes.
Angina pectoris is a serious condition. Without treatment as many as 5% of patients can die annually.

What causes angina pectoris?
Angina pectoris is the result of myocardial (heart tissue) ischaemia caused by an imbalance between myocardial blood supply and oxygen demand. Atherosclerosis is the most common cause of angina pectoris. These plaques in the blood vessels of the heart are unlikely to cause any symptoms unless they occlude more than 70% of the luminal diameter. Decrease blood and oxygen to the heart may also result from coronary spasm or vasoconstriction. Cigarette smoking and mental stress have been found to produce coronary artery vasoconstriction as well as use of cocaine.

Diagnosis
A careful clinical history is very important in establishing the diagnosis of angina pectoris. The discomfort of angina pectoris is typically produced by exertion or emotions and is relieved by rest (usually minutes) or sublingual nitroglycerin. Some patients have symptoms of angina at night (nocturnal angina).
Physical examination is used to rule out factors that could exacerbate or precipitate angina. These include aneamia, hypertension or congestive heart failure. During an attack of angina, many patients may appear pale, sweaty with increased heart rate and blood pressure.

Other tests
Various other tests are used to establish the diagnosis of angina pectoris. These include resting and exercise-stress electrocardiogram and radionuclide scintigraphy.

When to see your doctor?
Many individuals with angina pectoris do not go to see their doctor as they feel their symptoms are not too severe. Very often there is only minimal or no chest pain and individuals dismiss these symptoms to ‘gas” pains. All individuals with symptoms suggestive of angina should see their doctor for a full evaluation.

Prognosis
The prognosis for women over the age of 60 and men over the age of 45 years is similar. For women under the age of 60 the prognosis for women is much better than that for men. In one study, in men over the age of 45 years, about 50% had a myocardial infarction within 8 years of the onset of symptoms of angina pectoris. About 40% of men aged over 45 years died within 8 years of presentation.
Generally, older patients with angina have a greater risk of a cardiac (heart) event which is more likely to be fatal. Patients with an abnormal resting electrocardiogram (ECG) have a poorer prognosis than those with a normal ECG.

Treatment
The main goal of treatment in angina pectoris are relief of symptoms, slowing progression of disease and reduction of future events especially myocardial infarction and death.
Risk factor modification is important in individuals with angina pectoris. Risk factors include hypercholesterolaemia, tobacco use, hypertension, diabetes mellitus and sedentary lifestyle. Cessation of smoking is an important aspect of angina management. Smoking appears to amplify the effects of other risk factors for atherosclerosis.
Various drugs are available for the treatment of angina. Your doctor will explain these various drugs and their various effects.
Some patients with angina can have revascularisation especially if their symptoms are unacceptable.

Conclusion
Angina pectoris is a common clinical manifestation of ischaemic heart disease. There are many drugs available that can be used in the management of angina. These drugs have led to reduce deaths from cardiac complications of this condition. Reduction of risk factors is also important in the management of angina pectoris. The use of aspirin and abstinence from smoking have led to a marked reduction in deaths from heart conditions associated with angina pectoris. All individuals with symptoms suggestive of angina pectoris should see their doctor for a full evaluation and correct diagnosis of symptoms. Successful management of angina pectoris can help reduced deaths associated with heart conditions.

Dr Brett Hodge is a Family Physician and Specialist Obstetrician/Gynaecologist with a Medical Practice in the JOHNSON BUILDING in THE VALLEY.

Dr. Brett Hodge

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