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Angina is not a disease. It is a pain, a symptom of another disease, the very common condition calledatherosclerosis, which affects many arteries. In this case, the arteries concerned are the coronary arteries of the heart. These two arteries and their branchessupply the very active muscle of the heart with the blood it needs to keep beating. If they can provide enoughblood so that the heart muscle gets the amount of glucose fuel and oxygen it need for its energy supply, the heartgoes on beating painlessly. But if the coronary arteries have been narrowed and can’t get the blood to the heart muscle fast enough,abnormal levels of substances collect in the muscles to the point of causing pain. This pain is angina.
The full name for the symptom is angina pectoris. This is Latin for ‘pain in the chest’. The symptom is far morecommon in men than in pre-menopausal women. After the menopause, women who are not on HRT are as likelyto get angina as men are as they no longer have the same hormone protection. Angina occurs when arteriosclerosis has caused so much narrowing of the coronary arteries that they are not ableto supply enough blood to the heart muscle during exercise. In most cases angina doesn’t occur while you’re at rest. But the stronger or more prolonged the exertion, thegreater is the amount of blood that the heart needs. Healthy coronary arteries can pass enough blood to allow the heart to reach its maximum output without pain. Butnarrowing of the coronary arteries will always mean that there is a limit to the rate at which blood can get to theheart muscle, in spite of its needs.
Angina symptoms develop when the heart demands more oxygen than can be supplied or when the supply dropsbelow demand. Diagnosis
Chest pain that is always related to exertion is a fairly sure indication of angina. The diagnosis can be confirmedby a special test called an electrocardiogram (ECG) which produces a tracing of the electrical activity in the heart. Treatment
The drug glyceryl trinitrate (nitroglycerine) is highly effective in controlling the pain of angina. You can take it as atablet that dissolves under your tongue, and the pain is usually relieved in two to three minutes. The drug is alsoavailable in skin patches (transdermal patches) and as a spray (again for under the tongue), and all forms areavailable from a pharmacy without prescription. Nitrates have a powerful action in widening (dilating) arteries, including the coronary arteries, thus improving theblood supply to the heart muscle. Note that you should not take Viagra (sildenafil) if you take glyceryl trinitrate.
Page 1 of 4 - 14 March 2005 - 10:42 Crown copyright 2003 Taking low-dose aspirin daily helps prevent blood clotting and reduces the risk of heart attack. Mild or moderateangina may need further treatment by drugs such as beta blockers (eg Antenolol) or calcium-channel blockers (egNifedipine). Potassium-channel activator drugs also help to widen the coronary arteries. These drugs can slow the force ofcontraction of the heart and dilate the coronary arteries, thus reducing the demand for oxygen and increasingsupply to the heart.
For unstable angina the treatment is a daily 300 mg dose of aspirin, and injectable anticoagulants such asHeparin are administered in hospital. Nitrates and beta blockers may also be necessary.
An effective treatment for angina is to widen the narrowed coronary arteries by a procedure called coronaryangioplasty. This is done using a small-gauge tube called a balloon catheter. This has a sausage-shaped balloonsegment near one end and is pushed into the narrowed part of the artery. The balloon is then inflated to widen thenarrowed artery. The results are excellent, but the procedure may have to be repeated.
In other cases, a bypass operation may be considered more suitable. Segments of vein are used to provide a newchannel by which the blood can be shunted past the blocked part of the artery. Some surgeons prefer to connecta local artery from the chest wall to the narrowed coronary beyond the point of the block. Complications
Unstable angina is a severe and dangerous form of angina pectoris that is due to the breakdown of a plaque ofatherosclerosis in the coronary arteries and the formation of a blood clot (thrombosis) on the raw surface. There may also be tightening of the coronary artery (spasm). Pain becomes more frequent and prolonged, andmay occur at rest. It is no longer possible to predict the onset of pain in relation to a known amount of exertion,and the risk of a heart attack is high.
Unstable angina requires admission to hospital in order to provide supportive care and pain relief during an acuteattack and to prevent a heart attack. Prevention
Keeping within your exertion limits can prevent the frequency and severity of angina attacks. If you already haveangina it is not too late to try to improve the situation by trying to get as much exercise as you safely can.
A daily low dose of aspirin (e.g. 75-150mg) is recommended, and perhaps a lipid-lowering drug considered toreduce the risk of attacks. Definition
The pain of angina is related to the demands made on the heart, most commonly for the performance of physicalexercise, but also to cope with emotional reactions. The pain usually comes on after a fixed amount of exertion,such as walking a particular distance.
Angina pain may be of very variable severity, even in the same person, and may be affected by factors such ascold weather, a change of temperature as when going outside from a warm house, the strength of the wind, stateof mind, or the length of time since a meal.
The pain may be so mild as to be hardly a pain but more a feeling of uneasiness or pressure in the chest; or it Page 2 of 4 - 14 March 2005 - 10:42 Crown copyright 2003 may be so severe that it stops you moving. It often causes breathlessness and belching, and when the exertionceases, the angina settles.
It is quite common for angina to remain at a fairly constant level of severity for years. In such cases the affectedperson will know exactly how far he or she can walk before the pain starts. But with other sufferers, all thefeatures of angina may vary. In some cases the angina may be absent for weeks, months or even years. In othersit may increase in frequency and severity until there is severe disability or death. References
National Service Framework for Coronary Heart Disease, chapter 4 Stable Angina. (), 2000.
Management of stable angina. NHS Centre for Reviews and Dissemination. Effective Health Care Bulletin 1997,volume 3, pages 1-8.
Exercise-based rehabilitation for coronary heart disease (Cochrane Review). Jolliffe JA et al. The CochraneLibrary, Issue 1, 2002. Resource allocation for chronic stable angina: a systematic review of effectiveness, costs and cost-effectiveness Intravascular ultrasound-guided interventions in coronary artery disease: a systematic literature review, withdecision analytic modelling, of outcomes and cost-effectiveness. Berry E. Health Technology Assessment 2000, Coronary artery stents in the treatment of ischaemic heart disease: a rapid and systematic review. Meads C.
A rapid and systematic review of the clinical effectiveness of glycoprotein IIb/IIIa antagonists in the medical A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE(Action on Secondary Prevention through Intervention to Reduce Events). Bowker TJ et al. Heart 1996, volume75, pages 334-42.
A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results.
EUROASPIRE Study Group. (European Action on Secondary Prevention through Intervention to Reduce Events).
European Heart Journal 1997, volume 18, pages 1569-82.
Coronary revascularisation in the management of stable angina pectoris: a national clinical guideline. ScottishIntercollegiate Guidelines Network (SIGN), 1998, pages 19-21.
Nicorandil for angina. Drug & Therapeutics Bulletin 1995, volume 33, pages 89-92.
Too many beta-blockers. Drug & Therapeutics Bulletin 1996, volume 34, pages 49-52.
Page 3 of 4 - 14 March 2005 - 10:42 Crown copyright 2003 Which prophylactic aspirin? Drug & Therapeutics Bulletin 1997, volume 35, pages 7-8.
Generic medicines - Can quality be assured? Drug & Therapeutics Bulletin 1997, volume 35, pages 9-11.
Safety of calcium-channel blockers. MeReC Bulletin 1998, volume 9, pages 13-16.
Angina. Bandolier 1997, issue 40, page 3. Page 4 of 4 - 14 March 2005 - 10:42 Crown copyright 2003


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