Angina Pectoris

Overview 

• Initially, Coronary atheroma is by far the most common cause of angina, although the symptom may be a manifestation of other forms of heart disease, particularly aortic valve disease and hypertrophic cardiomyopathy. [5]

Causes 

• It may occur whenever there is an imbalance between myocardial oxygen supply and demand
• Myocardial Ischemia

Factors influencing myocardial oxygen supply and demand.

Oxygen demand: cardiac work i.e.:

• Blood pressure
• Myocardial contractility
• Left ventricular hypertrophy
• Valve disease, e.g. aortic stenosis
• Heart rate[5]

Oxygen supply: coronary blood flow i.e.:

• Duration of diastole
• Coronary perfusion pressure
• Coronary vasomotor tone
• Oxygenation[5]

Precipitating Cause i.e.:

• Physical exertion
• Heavy meal
• Exposure to cold
• Emotion also excitement particularly anxiety and anger
• Hyperinsulinism in diabetic patients [1]

Classification of Angina Pectoris

1. Stable Angina: –

• Angina is said to be stable when there has been no change in the frequency, duration, precipitating factors, or ease of relief of angina attacks during last 60 days.
• Pain lasts for 1-5 minutes.
• ECG: ST segment depression[1][2]

2. Unstable Angina: –

• Heart does not get enough blood also oxygen.
• Patients with new onset angina that is severe and frequent
• Patients with accelerating angina.
• Angina at rest.[2]

Risk factor of Angina Pectoris

• Hypertension
• Hyper lipidaemia– e.g. Arcus senilis, xanthelasma, or cholesterol deposits along tendons and in skin of palms and buttocks
• Obesity
• Diabetes also its accompaniments [1]a

Pathogenesis

Angina pectoris is caused by an imbalance between myocardial oxygen demand and supply. The most common cause of this imbalance is a fixed obstruction of a coronary blood vessel caused by atherosclerosis, but other causes may also be involved.

Atherosclerosis:

• The primary cause of angina in most patients is a fixed obstruction of one or more coronary arteries caused by atherosclerosis. This leads to a reduction in coronary blood flow, which is insufficient to meet the oxygen demands of the myocardium during periods of increased demand, such as exercise or emotional stress.

Other Causes:

• While atherosclerosis is the most common cause, other factors can contribute to the development of angina, including coronary artery spasm, microvascular dysfunction, abnormal hemoglobin, and increased myocardial oxygen demand. [10]

Pathophysiology of Angina Pectoris

Acute myocardial ischemia occurs when myocardial oxygen demand exceeds supply

1. Coronary atherosclerotic narrowing
2. Non-atherosclerotic coronary artery disease – Coronary spasm, coronary thromboembolism, congenital anomalies, coronary vasculitis
3. Valvular heart disease – Mitral valve prolapse
4. Pulmonary hypertension
5. Systemic hypertension
6. Either hypertrophic or dilated cardiomyopathy
7. Anaemia – from tachycardia and reduction in O2 availability.

Clinical Features of Angina Pectoris

Chest Pain/Discomfort:

• The hallmark of angina pectoris is chest pain or discomfort, often described as a squeezing, pressure, heaviness, tightness, or burning sensation. The pain typically occurs beneath the sternum (breastbone) and may radiate to the left arm, shoulder, neck, jaw, or back.

Provoking Factors:

• Angina is typically precipitated by exertion or emotional stress and relieved by rest or nitroglycerin. The intensity and duration of pain may vary among individuals and even within the same individual at different times.

Associated Symptoms:

• Patients may experience additional symptoms during an angina episode, such as shortness of breath, nausea, vomiting, sweating, lightheadedness, or weakness.

Atypical Presentations:

• Some individuals, particularly women, the elder peoples, and patients with diabetes, may present with atypical symptoms, such as epigastric discomfort, dyspnea, or fatigue.

Important Considerations:

• The clinical presentation of angina can vary widely, and a thorough history and physical examination are essential for accurate diagnosis and risk assessment.
• Atypical presentations of angina are more common in certain populations and should be considered, especially in patients with risk factors for coronary artery disease.
• Early recognition and prompt evaluation of angina are crucial for preventing complications and improving outcomes. [11]

Sign & Symptoms of Angina Pectoris

Signs:

• No signs
• LV dysfunction
• Ischemia
• Dysfunction of papillary muscle
• Pallor and sweating with rise of BP often tachycardia
• Slowing of pulse
• Pain[1]

Symptoms:

1. Anginal Pain or Distress i.e.:

• Site i.e.: Middle or lower sternum or over left pericardium, upper arm, lower jaw
• Radiation i.e.: May spread to right or left arm or both, neck or jaw.
• Character i.e.: Vice-like constriction or choking. After that, Sometimes only pressure or burning pain, rarely mere weakness of one or both arms.
• Duration i.e. : Most commonly 1 to 4 minutes. Additionally, it may force patient to stop walking

2. Dyspnoea
3. Other Symptoms i.e.:

• Choking sensation in throat or feeling of impending doom.
• Either belching or passage of flatus or polyuria after an attack.
• Dizziness, faintness or rarely syncope.
• If pain is severe, sweating also nausea.[1]

Clinical Examination

Physical Examination

• The physical examination may be entirely normal in patients with stable angina pectoris.
• A patient may present with hypertension, a major risk factor for coronary artery disease.

Examination of the cardiovascular system during ischemia, however, may reveal:

• Elevated blood pressure
• Transient third heart sound (S3 – ventricular filling sound) and fourth heart sound (S4 – atrial filling sound)
• A sustained outward (dyskinetic) systolic movement of the left ventricular apex
• A murmur of mitral regurgitation
• Paradoxical splitting of the second heard sound bibasilar lung crackles and chest wall heave

• The physical examination should also focus on the detection of abnormal findings which might be suggestive of left and right heart failure and of non ischemic causes of angina pectoris (valvular aortic stenosis, cardiomyopathy and pulmonary hypertension).

Cardiovascular assessment should also include:

• Examination of peripheral arterial pulses
• Evaluation of retinal fundus for vascular changes
• Screening for risk factors of coronary artery disease (CAD)
• Stigmata of genetic dyslipidemia syndromes such as:

• Tendon xanthomas
• Xanthelasma
• Corneal arcus, particularly in patients under 50 years of age

• Since the presence of non-coronary atherosclerotic disease increases the likelihood of the presence of coronary artery disease, a careful examination should include attention to:

• Peripheral arterial pulses
• Auscultation of the carotid arteries for bruits
• Palpation of the abdomen for aneurysm[6]

Diagnosis of Angina Pectoris

• IECG at rest i.e.: either normal or show ST-T changes.
• Holter monitoring i.e.: episodes of either painful or painless myocardial Ischemia.
• Stress testing i.e.: Cardiovascular stress can be provoked physically by exercise, or pharmacologically.
• Coronary angiography i.e.: technique for diagnosis and planning treatment of IHD. [1]

Differential Diagnosis

Complications of Angina Pectoris

Investigation of Angina Pectoris

• Echocardiography i.e.: Identify areas of segmentally reduced contraction corresponding to previous MI
• Stress echocardiography i.e.: Image comparison is used to determine the extent and distribution of wall motion abnormalities
• Intravascular ultrasonography i.e.: Defines completely the vessel wall, plaque burden, morphology of the plaque, presence of calcification in the lesion, also luminal dimensions
• Intracoronary Doppler i.e.: Clinical applications include assessment of functional significance of intermediate lesions by coronary arteriography. [1]a

Treatment of Angina Pectoris

• Calcium antagonists (diltiazem – DOC).
• β-blockers are contraindicated in Prinzmetal’s variant.

Coronary Revascularization i.e.:

• Percutaneous transthoracic coronary Angiography
• Coronary artery bypass grafting. [2]

Acute attack – Glyceryl trinitrate 0.6 mg or isosorbide dinitrate 5 mg sublingually, or nitrite spray in a measured dose of 0.4 mg. Moreover, Effect starts in 3 to 5 minutes and its action lasts for 20 to 40 minutes. Contraindicated in patients with glaucoma.[1]

Prevention

Lifestyle changes are also important in preventing heart disease and angina. These include:

Control blood pressure:

• Keep your blood pressure readings within a healthy range with lifestyle changes and medications, if needed.

Stop Smoking:

• Smoking is the No. 1 cause of preventable death in the U.S.
• Quitting smoking also is one of the best changes you can make to help prevent a heart attack.

Exercise:

• Staying active is important for your heart. You should try to exercise (brisk walking, running, or biking) for 30 minutes at least five times a week.
• This can reduce blood pressure, increase HDL (good) cholesterol, and improve control of sugar, called glucose, in your blood.

Healthy diet:

• Everyone – especially if you have heart disease or a higher chance of developing heart disease – should eat a well-balanced diet high in fruits, vegetables, whole grains, fish and lean meats.
• Stay away from sugary beverages, refined grains, and processed or red meats.

Stress reduction:

• Stress is physical, mental, or emotional strain or tension. Low to moderate levels of stress can be healthy by increasing motivation and productivity.
• However, chronic high levels of stress can lead to heart disease and angina.
• A well-balanced life is important for heart health.
• If you experience stress that causes or worsens your symptoms of angina, talk about these symptoms with your health care professional.[8]

Homeopathic Treatment of Angina Pectoris

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. In addition, The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Angina Pectoris:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicine:

1. Arnica Montana:

• After debilitated with impoverished blood, cardiac dropsy also Dyspnoea.
• A muscular tonic – affected the venous system inducing stasis. Heart – Angina Pectoris – pain especially severe in elbow of left arm. Stitches in heart.
• Pulse feeble and irregular. Cardiac dropsy with distressing Dyspnoea. Additionally, Fatty heart and hypertrophy.

2. Aconite:

• Intense anxiety, with fear of death; coldness, cold sweat; feeble pulse or full, strong and throbbing; intense pain in all directions; frequent change of position without relief, but no exhaustion.
• Suffocative constriction of chest, so distressing that he sweats from agony; flushed face also pain in cardiac region, going down left arm.
• General or local numbness and tingling, particularly in recent cases occurring in strong plethoric subjects.

3. Agaricus:

• Angina pectoris, gastralgia form; constant feeling of a lump in epigastrium, with pain under sternum; drawing in region of diaphragm, In addition sharp pains in left side.
• Faintness with an empty feeling; heaviness of stomach, sometimes alternating with a jerking sensation, as of some heavy object; constriction of chest.

4. Bryonia:

• Attacks from mental excitement or fright. Additionally, cutting pain in right chest above the sixth rib inside the base of nipple, extending down the left arm.
• The slightest motion brings on attacks; constant, dull pain in left arm to the fingers.
• Sensation of great oppression, it seems as if something should expand but will not.

5. Carbo veg:

• Suffocative constriction of chest, morning in bed.
• Burning in cardiac region; precordial anguish as though he would die.

6. Chininum Ars:

• Angina pectoris, also dropsical symptoms.
• Venous hyperemia and cyanosis.

7. Digitalis:

• Abnormal action of the heart; sense of oppression, therefore tendency of fainting.
• Feeble or spasmodic pulse; also oppression of the chest
• Pain extending to the head and left arm; mental anguish, with vertigo and fainting.
• Heart’s action more vigorous than the pulse.
• Moreover, In advanced cases, when the disease sets in suddenly, drawing, tensive, spasmodic pains in left chest and sternum, towards nape of neck and upper arm; also indescribable deathly anguish when paroxysms come closer together during progress of disease; skin pale, cold.

8. Kalmia:

• Angina pectoris in fatty degeneration of heart.
• Furthermore, Pulse slow and feeble.

9. Lachesis:

• Anxious pain with beating of the heart; frequent attacks of fainting daily, additionally nausea.
• Difficult breathing, palpitation and cold sweat.
• Choking, constricting or rising in throat, also organic disease of the heart.
• Furthermore, Inability to lie down or to speak; very distressed after a short sleep.

10. Nux Vomica:

• Haemorrhoidal tendency; constrictive pain in thorax, as if sternum were pressed inward.
• Stitches in cardiac region, palpitations; especially at night in bed or towards morning.
• Aggravation from mental emotions, protracted study, after that eating.[3]

Diet & Regimen of Angina Pectoris

• Eat plenty of fruits, vegetables, and whole grains.
• Choose lean proteins, such as skinless chicken, fish, and beans.
• Eat non-fat or low-fat dairy products. For instance, skim milk and low-fat yogurt.
• Moreover, Avoid foods that contain high levels of sodium (salt).
• Read food labels. In addition, Avoid foods that contain saturated fat and partially hydrogenated or hydrogenated fats. In conclusion, these are unhealthy fats that are often found in fried foods, processed foods, and baked goods.
• Eat fewer foods that contain cheese, cream, or eggs.[4]

Do’s & Don’t 

Angina pectoris, commonly known as angina, is chest pain or discomfort caused by reduced blood flow to the heart muscle. Here are some do’s and don’ts for managing angina pectoris:

Do’s

1. Take Your Medications:
   • Follow your doctor’s prescription for medications like nitroglycerin, beta-blockers, calcium channel blockers, or aspirin.

2. Monitor Your Symptoms:

   • Keep a diary of your angina attacks, noting the time, duration, triggers, and intensity of the pain.

3. Adopt a Heart-Healthy Diet:

   • Eat a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats.
   • Limit intake of saturated fats, trans fats, cholesterol, and sodium.

4. Exercise Regularly:

   • Engage in moderate physical activity as recommended by your doctor. Walking, cycling, and swimming are good options.
   • Avoid strenuous activities that might trigger angina.

5. Manage Stress:

   • Practice relaxation techniques such as deep breathing, meditation, yoga, or tai chi.
   • Consider counseling or therapy if you have chronic stress or anxiety.

6. Maintain a Healthy Weight:

   • Aim for a healthy body weight to reduce the strain on your heart.

7. Control Other Health Conditions:

   • Manage diabetes, high blood pressure, and high cholesterol through medications and lifestyle changes.

8. Quit Smoking:

   • Seek help to stop smoking, as it is a major risk factor for heart disease.

9. Limit Alcohol Consumption:

   • Drink alcohol in moderation, if at all, following your doctor’s advice.

10. Carry Your Medication:

    • Always have your nitroglycerin or other prescribed medications with you in case of an angina attack.

Don’ts

1. Ignore Symptoms:

   • Don’t dismiss chest pain or discomfort. Seek immediate medical attention if you experience severe or prolonged angina.

2. Overexert Yourself:

   • Avoid heavy lifting, extreme physical activities, or sudden bursts of exertion.

3. Consume Unhealthy Foods:

   • Steer clear of foods high in unhealthy fats, sugar, and salt, which can worsen heart conditions.

4. Neglect Regular Check-Ups:

   • Don’t skip follow-up appointments with your healthcare provider.

5. Ignore Risk Factors:

   • Don’t overlook other conditions like hypertension, diabetes, or high cholesterol that can exacerbate angina.

6. Stress Your Heart:

   • Avoid situations that cause unnecessary stress or anxiety.

7. Discontinue Medications Abruptly:

   • Don’t stop taking prescribed medications without consulting your doctor.

8. Drink Excessively:

   • Avoid excessive alcohol consumption, which can negatively affect heart health.

9. Smoke:

   • Don’t smoke or use tobacco products in any form.

10. Delay Medical Help:

    • Don’t wait too long to seek medical assistance if your symptoms worsen or change.

Emergency Situations

• Recognize Signs of a Heart Attack:

  • If you experience chest pain that spreads to your arm, neck, jaw, or back, shortness of breath, sweating, nausea, or lightheadedness, seek emergency medical help immediately.

Terminology

Medical Terms:

• Angina Pectoris: Chest pain or discomfort caused by reduced blood flow to the heart muscle.
• Myocardial Ischemia: A condition where the heart muscle doesn’t receive enough blood and oxygen.
• Atherosclerosis: The buildup of fats, cholesterol, and other substances in and on the artery walls, leading to narrowing or blockage.
• Coronary Arteries: Blood vessels that supply the heart muscle with oxygen-rich blood.
• Myocardium: The muscular tissue of the heart.
• Coronary Artery Disease (CAD): A condition in which the coronary arteries become narrowed or blocked, often due to atherosclerosis.

• Stable Angina: Angina that occurs predictably during exertion and is relieved by rest or medication.
• Unstable Angina: Angina that is new, worsening, or occurs at rest, signaling a higher risk of heart attack.
• Prinzmetal Angina: Angina caused by spasms in the coronary arteries.
• Hypertension: High blood pressure.
• Hyperlipidemia: High levels of fats (lipids) in the blood, including cholesterol and triglycerides.
• Echocardiography: An ultrasound of the heart used to assess its structure and function.
• Coronary Angiography: An X-ray procedure that uses dye to visualize the coronary arteries and identify blockages.
• Acute Coronary Syndrome (ACS): A range of conditions associated with sudden, reduced blood flow to the heart, including unstable angina and heart attack.
• Arrhythmias: Abnormal heart rhythms.
• Heart Failure: A condition in which the heart cannot pump blood effectively.
• Sudden Cardiac Death: Unexpected death caused by a loss of heart function.

Homeopathic Terms:

• Homeopathy: A system of alternative medicine based on the principle of "like cures like."
• Remedy: A substance used in homeopathy to treat specific symptoms.
• Potency: The degree to which a homeopathic remedy has been diluted and succussed (shaken).
• Miasmatic Tendency: A predisposition or susceptibility to certain types of diseases in homeopathy.

References use for Article Angina Pectoris

1. Golwala’s Medicine for student 25th edition 2017
2. Pradip Kumar Das – A Systematic Review of Subjects for PG Medical Entrance Examinations
3. Homoeopathic Therapeutics By Lilienthal
4. https://medlineplus.gov/ency/patientinstructions/000576.htm#:~:text=Eat%20plenty%20of%20fruits%2C%20vegetables, levels%20of%20sodium%20(salt).
5. Davidsons Principles and Practice of Medicine (PDFDrive.com)
6. https://www.wikidoc.org/index.php/Chronic_stable_angina_physical_examination
7. https://www.ncbi.nlm.nih.gov/books/NBK559016/
8. https://www.cardiosmart.org/topics/angina/prevention
9. Cardiovascular Diseases- An Epidemic That’s | GE HealthCare (India)
10. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition (2019), by Douglas P. Zipes, William J. Stevenson, Joseph Loscalzo

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