The term Angina Pectoris is
applied to varying forms of transient chest discomfort that are attributable to
insufficient myocardial oxygen. The heart is the pump responsible for
circulating blood throughout the body. Myocardium is the heart muscle that
contracts to pump that blood and like any other muscle. Angina pectoris
describes the discomfort, pain, or any other symptoms that occur when blood flow to
heart muscle cells is not enough to meet its energy needs. The classic
description of angina is a crushing pain that radiates around the chest and sometimes down the arm or into the back, which is usually aggravated
by exertion or stress.Angina is a warning sign that the heart muscle is not
getting adequate blood supply and oxygen. If unheeded it may lead to a heart
attack or myocardial infarction. Angina isn’t a disease; it’s a symptom of an
underlying heart problem. Angina usually
is a symptom of Coronary Heart Disease (CHD).
Stable Angina: The pain is
predictable and present only during exertion or extreme emotional distress, and
it disappears with rest. Stable angina isn't a heart attack more likely to
happen in the future.
It may occur more often and be more severe than stable angina. The Unstable angina can occur with or may be
without physical exertion, and rest may not relieve the pain. The angina may occur
frequently, more easily at rest condition, feel more severe and last longer
Although this type of angina can often be relieved with drugs because it is
unstable and may lead to a heart attack. Intense treatment is required. This
type of angina is a sign that a heart attack may happen soon.
(Vasospastic or Prinzmetal’s Angina): This is when angina occurs at rest
specially during sleeping or when exposed to cold temperatures.The symptoms are
caused by decreased blood flow to the heart muscle from a spasm of the coronary
artery. The majority of people with this type of angina also have coronary
artery disease CAD.
Angina pectoris is the most
common clinical manifestation of myocardial ischemia. Myocardial ischemia develops when
coronary blood flow becomes inadequate to meet myocardial oxygen O2 requirement.
This causes cardiac cells to switch from aerobic to anaerobic metabolism, with
a progressive impairment of metabolic, mechanical, and electrical functions.
Increases in the heart rate and myocardial contractile state result in
increased cardiac oxygen demand. Increases in both afterload (ie, aortic
pressure) and preload (ie, ventricular end-diastolic volume) result in a
proportional elevation of myocardial wall
tension and oxygen demand. Supply of oxygen to organ
is determined by blood flow and the extraction of oxygen. There for an increase oxygen demand (eg, during exercise) must be
met by a proportional increase in coronary blood flow.
Atherosclerosis is the most common cause of epicardial coronary
artery stenosis and angina pectoris. The patients who have fixed coronary
atherosclerotic lesion of at least 50% show myocardial ischemia during
increased myocardial metabolic demand. Fixed atherosclerotic lesions of at
least 90% patients may experience angina at rest.
Myocardial ischemia can also be
the result of factors affecting blood composition as is observed with severe
anemia (hemoglobin, < 8 g/dL), or elevated levels of carboxyhemoglobin.
Chest pressure that radiates down the
arm, into the neck or jaw. However, patients may use different words to describe
the pain, tightness and ache. The
location may be in the chest; instead it
may be described in the upper abdomen, back, arms, shoulder, or neck.Breath shortness
, nausea /vomiting ,sweatingand light headache
Physical examination also helpful for the potential list of diseases but in of
itself, will not make the formal diagnosis.The physician will examine at your skin for good color, which shows that
your body is getting a good supply of oxygen-rich blood.The doctor will measure
your blood pressure (Blood pressure is the force (pressure) exerted in the
arteries by the blood as it is pumped around the body by the heart.The doctor
will check for swelling a sign that your heart is not pumping efficiently.Your
doctor will use a stethoscope to listen closely to the sounds the heart makes
with each heartbeat. An S4 heart sound may be present during myocardial
ischemia due to the lack of ATP production impairing left ventricular
relaxation (S4 heart sound occurs when a non-compliant, stiffened( LV) left
ventricle receives blood after atrial contraction) Abnormal sounds include:Murmur: An
abnormal whooshing sound made by blood flowing abnormally through heart. Click:
An abnormal sound made by a valve that is stiff or stenotic (narrowed).
The described symptoms may of
one of the following conditions ; Pneumonia, GI indigestion, MI, Asthema, Heart
Chest X-ray: This test takes images of your heart
and lungs. A chest-x ray can reveal signs of heart failure.
Blood tests: Certain heart
enzymes ((troponin, CPK, myoglobin) slowly leak out into your blood if your
heart has been damaged by a heart attack. Blood can be tested for the presence
of these enzymes. Blood tests also check
the levels of certain fats, cholesterol, sugar, proteins, and hemoglobin
(ECG or EKG).
Each beat of your heart is triggered by an electrical impulse generated from
special cells in heart. An electrocardiogram shows if the blood flow through
your heart has been slowed or interrupted or if you're having a heart
attack. The currents of injury are represented
by deviation of the ST segment on the surface ECG.
The ECG at rest is normal in
50% or more of patients with stable angina. But an ECG obtained during chest
pain is abnormal in 50% of patients with angina who have normal resting ECG.
The ST segment can either be elevated or depressed. Myocardial ischemia is
suggested by an ST segment depression. ST elevation may occur in Prinzmetal's
Tolerance Test (ETT): Sometimes angina is easier to diagnose when your
heart is working harder. During exercising blood pressure is monitored and your
ECG readings are watched, develop marked ST-changes at low level exercise. Exercise ECG testing may reveal
exercise-induced myocardial ischaemia. It is more sensitive and specific than
the resting ECG in detecting myocardial ischemia. Exercise ECG
is abnormal in 85% of patients with angina. If you're unable to exercise, you
may be given drugs that cause your heart to work harder to simulate exercising.
In case of unstable angina ST segment is deep
but inverted T-wave which becoming normal again after the end of the anginal
This test involves having an injection of a small amount of Thalium. This
substance mixes with your blood and travels to your heart. A special scanner —
which detects the radioactive material in your heart — creates images of your
heart muscle. This is done both when you are resting and when your heart is
beating faster. You may be asked to increase your heart rate by exercising (eg ,
by walking/ jogging on a treadmill).
angiography uses X-ray imaging to examine the inside of your heart's blood
vessels. In coronary angiography dye
that's visible by X-ray machine is injected into the blood vessels of your
heart, by cardiac catheterization. A catheter is put into a blood vessel in
your arm, groin (upper thigh), or neck. The tube is threaded into your coronary
arteries CA the dye is released into bloodstream. These shows up the structure
of the arteries (like a road map) and can show the location and severity of any
The main goals of treatment in
angina pectoris are to decrease Oxygen demand , to increase Oxygen supply, to
relieve the symptoms, especially MI and premature death.
breaks if exertion triggers angina also
avoid large meals /rich foods that leave feeling stuffed. And try to avoid
situations of upset/stressed and quit smoking.
can be used for acute relief of angina and prophylactically before activities
that may precipitate angina or on a long-term preventive basis. . Nitrates dilate your blood vessels and
decrease workload on heart.
Aspirin may be
recommended to make platelets less sticky to prevent clot formation making it
easier for blood to flow through narrowed heart arteries and prevent heart
Certain medications such as clopidogrel
(Plavix), prasugrel (Effient) and ticagrelor (Brilinta) can help prevent blood
clots from forming by making your blood platelets less likely to stick
Statins are drugs
used to lower blood cholesterol. They work by blocking a enzyme your body needs
to make cholesterol.
Beta-blockers are also used
for symptomatic relief of angina and prevention of ischemic events. They
reducing myocardial oxygen demand and by decreasing the heart rate and
myocardial contractility (decrease cardiac workload), thereby reducing blood
pressure. They dilate blood vessels and improve blood flow, thus reducing or
preventing angina. Beta-blockers have been shown to reduce the rates of mortality
and morbidity following acute MI.
Calcium channel blockers dilate both coronary
and peripheral blood vessels. Long-acting heart rate–slowing
(Dihydropyridine) calcium channel blockers can be used to control anginal
symptoms in patients with a contraindication to beta-blockers and in those in
whom symptomatic relief of angina cannot be achieved with the use of
beta-blockers and nitrates.
Angioplasty: In this
procedure a tiny wire with a balloon at the end is put into a large artery in
your groin or arm. The balloon is blown up inside the narrowed part of the
artery to open it wide again.
involves an operation (Coronary Artery Bypass Grafting surgery) to bypass the
narrowed sections of arteries with healthy blood vessel segments (grafts) which
are taken from other parts of the body and more blood can then get past into
the heart muscle [4,5].
Questions regarding the Angina Pectoris,
pathophysiology ,sign and symptoms Physical examination, diagnostic tests and
treatment were asked.The data presented here is
collected by approaching to third and fifth year Pharm-D students. The survey
proceeded for two weeks. 50 forms were duly filled by people. Sample population
is being divided equally in 25 filled performas of both groups. Since our study
was not experimental and didn't involve any intervention, we didn't approach
any ethics committee for review before conducting the study. All the data
was entered in SPSS version 20 and evaluated. Results have been presented in
the form of frequencies and percentages where applicable.
RESULT AND DISCUSSION
Out of the total 150 students,
only 50 of them participated in the study. Knowledge about sign and symptoms of
angina pectoris was adequate among third year as well as final year students
(table #1). The level of awareness among the two groups of students was
significant (P < 0.05) for knowledge about physical exam and
diagnostic test. However, there is a highly significant (P < 0.005)
difference among the studied groups for knowledge about treatment of AP. The
results are non significant for awareness about “what is angina” sign and
symptoms, physical examination among students of third professional as well as
fifth year Pharm-D students (table 1). We’ve determined the awareness ratio and
found out that the awareness rate of AP was not up to the mark as we thought.
Among the study sample students of fifth year Pharm-D showed good knowledge and
awareness about AP. Results of the present study showed that most of the fifth
year Pharm-D students showed 50% or 100% awareness for most of the questions
asked when compared with third year Pharm-D students.
Awareness about angina in third and fifth year students
Fig 2:Awareness about signs and symptoms in third and
fifth year students
3:Awareness about physical examination in third and fifth year students
4:Awareness about types of angina in third and fifth year students
5:Awareness about diagnostic tests of angina in third and fifth year students
6:Awareness about treatment in third and fifth year students
The reason was their poor
understanding and knowledge regarding the subject. By using SPSS software we
apply independent sample t-test .p
values for what is angina in both group is .107 with degree of freedom
48.Similarly p value for 2-5 question
are 0.69,0.012,0.027,0.000 with df 48.Results are given in table 1 and
in figure 1-6.