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Angina Pectoris

Practice Essentials

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. It is a common presenting symptom (typically, chest pain) among patients with coronary artery disease (CAD). Approximately 9.8 million Americans are estimated to experience angina annually, with 500,000 new cases of angina occurring every year.

Signs and symptoms

Patients should be asked about the frequency of angina, severity of pain, and number of nitroglycerin pills used during episodes. Symptomatology reported by patients with angina commonly includes the following:

Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking sensation) as opposed to frank pain

Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders

Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for about 1-5 minutes and relieved by rest or nitroglycerin

Pain intensity that does not change with respiration, cough, or change in position

Angina decubitus (a variant of angina pectoris that occurs at night while the patient is recumbent) may occur.

The following should be taken into account in the physical examination:

For most patients with stable angina, physical examination findings are normal

A positive Levine sign suggests angina pectoris

Signs of abnormal lipid metabolism or of diffuse atherosclerosis may be noted

Examination of patients during the angina attack may be more helpful

Pain produced by chest wall pressure is usually of chest wall origin

See Clinical Presentation for more detail.

Diagnosis

Diagnostic studies that may be employed include the following:

Chest radiography: Usually normal in angina pectoris but may show cardiomegaly in patients with previous MI, ischemic cardiomyopathy, pericardial effusion, or acute pulmonary edema

Graded exercise stress testing: This is the most widely used test for the evaluation of patients presenting with chest pain and can be performed alone and in conjunction with echocardiography or myocardial perfusion scintigraphy

Coronary artery calcium (CAC) scoring by fast CT: The primary fast CT methods for this application are electron-beam CT (EBCT) and multidetector CD (MDCT)

Other tests that may be useful include the following:

ECG (including exercise with ECG monitoring and ambulatory ECG monitoring)

Selective coronary angiography (the definitive diagnostic test for evaluating the anatomic extent and severity of CAD)

See Workup for more detail.

Management

General treatment measures include the following:

Encouragement of smoking cessation

Treatment of risk factors (eg, hypertension, diabetes mellitus, obesity, hyperlipidemia)

In patients with CAD, efforts should be made to lower the low-density lipoprotein (LDL) level (eg, with a statin). Current Adult Treatment Panel III (ATP III) guidelines are as follows
:

In high-risk patients, a serum LDL cholesterol level of less than 100 mg/dL is the goal

In very high-risk patients, an LDL cholesterol level goal of less than 70 mg/dL is a therapeutic option

In moderately high-risk persons, the recommended LDL cholesterol level is less than 130 mg/dL, but an LDL cholesterol level of 100 mg/dL is a therapeutic option

Non-high-density lipoprotein (HDL) cholesterol level is a secondary target of therapy in persons with high triglyceride levels (>200 mg/dL); the goal in such persons is a non-HDL cholesterol level 30 mg/dL higher than the LDL cholesterol level goal

Patients with established CAD and low HDL levels are at high risk for recurrent events and should be targeted for aggressive nonpharmacologic and pharmacologic treatment. The currently accepted management approach is as follows:

In all persons with low HDL cholesterol levels, the primary target of therapy is to achieve the ATP III guideline LDL cholesterol level goals with diet, exercise, and drug therapy as needed

After the targeted LDL level goal is reached, emphasis shifts to other issues; in patients with low HDL and high triglyceride levels, the secondary priority is to achieve the non-HDL cholesterol level goal (30 mg/dL higher than the LDL goal); in patients with isolated low HDL cholesterol levels and triglyceride levels below 200 mg/dL, drugs to raise HDL can be considered

Other pharmacologic therapies that may be considered include the following:

Enteric-coated aspirin

Clopidogrel

Hormone replacement therapy

Sublingual nitroglycerin

Beta blockers

Calcium channel blockers

Angiotensin-converting enzyme (ACE) inhibitors

Injections of autologous CD34+ cells

Revascularization therapy (ie, coronary revascularization) can be considered in the following:

Patients with left main artery stenosis greater than 50%

Patients with 2- or 3-vessel disease and left ventricular (LV) dysfunction

Patients with poor prognostic signs during noninvasive studies

Patients with severe symptoms despite maximum medical therapy

The 2 main coronary revascularization procedures are (1) percutaneous transluminal coronary angioplasty, with or without coronary stenting, and (2) coronary artery bypass grafting. Considerations for choosing a procedure include the following:

Patients with 1- or 2-vessel disease and normal LV function who have anatomically suitable lesions are candidates for percutaneous transluminal coronary angioplasty and coronary stenting.

Drug-eluting stents can remarkably reduce the rate of in-stent restenosis

Patients with significant left main coronary artery disease, 2- or 3-vessel disease and LV dysfunction, diabetes mellitus, or lesions anatomically unsuitable for percutaneous transluminal coronary angioplasty have better results with coronary artery bypass grafting

Other procedures that may be considered include the following:

Intra-aortic balloon counterpulsation (in patients who continue to have unstable angina pectoris despite maximal medical treatment): This should be followed promptly by coronary angiography with possible coronary revascularization

Enhanced external counterpulsation (in patients whose angina is refractory to medical therapy and who are not suitable candidates for either percutaneous or surgical revascularization)

Laser transmyocardial revascularization (experimental)

Use of the Coronary Sinus Reducer (Neovasc Medical, Inc, Or Yehuda, Israel), a percutaneous implantable device designed to establish coronary sinus narrowing and elevate coronary sinus pressure (further studies needed)

See Treatment and Medication for more detail.

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