Angina is a very common heart disease responsible for producing severe, recurring pain and tightness over the chest. It is invariably brought about by exercise or emotional stress, and is nearly always relieved by physical rest or the administration of medication. It is commonly referred to as angina.
Clinically, it is more accurately called angina pectoris, or angina of effort. It sometimes goes by the name Ileberden’s angina, because it was first described by William I leberden in 1768. However, it was not recognised as being a heart disease until the present century.
Angina is another serious disease produced by narrowing of the arteries that supply blood to the heart muscle. If these become diseased through the walls thickening (thus reducing the diameter of the artery), then additional supplies of blood become unavailable to the heart fibres when they are needed most – that is, when exercise or emotional situations make these extra demands.
Atheroma and hardening of the artery walls takes place. These areas may coalesce and form the arterial disease known as atherosclerosis (also called arteriosclerosis). Many of the factors that produce this have already been clearly outlined. It is worth spending a few minutes at this juncture in reviewing some of the causes, for this is one of the end products of blood-vessel disease in the heart.
Chest pain brought about by exercise and other stimuli and relieved by rest is the typical picture of angina. Although there is considerable variation in the nature and extent of the pain, its basic nature is surprisingly constant. Typically, the pain is situated over the sternum (breastbone). From here it tends to spread over the chest in a vicelike manner. It tends to traverse to the right and the left (more frequently the left) pectoral region, which is generally the large muscular region under the nipple.
It continues to spread, varying in intensi- ty with the degree of vascular involvement, upwards into the neck, shoulders and down the arms. Again, the left arm is more frequently affected. It goes down the left arm, to the elbow, and still further down the inner side of the arm, often affecting the fingers and hand.
From the upper chest region, it may spread to the face, involving the face, cheek, jaw, and even teeth and gums. Almost invariably the front part of the chest is involved. But it may be below the chest, in the epigastrium area. Pain may spread to the shoulders and affect the area between the shoulder blades.
Patients suffering from this disability often describe their pain as “vicelike,” “constricting,” “crushing,” “pressing,” a “sensation of a heavy weight being on the chest,” a “rawness and burning in the shoulder region.” The pain tends to he remarkably constant throughout the duration of an attack. There is no shooting, stabbing, pricking sensation, and the pain is not related to movements of the chest wall that occur during respiration (common with chest infections, such as pleurisy and bronchitis). Often this feature can assist in the diagnosis of the disability.
Physical activity usually brings on the attack. In the very first instance, activity far in excess of what the patient would be customarily carrying out may herald the attack. However, after the initial bout, subsequent attacks tend to occur with increasing frequency. Even walking may initiate symptoms, and an increase in the rate of walking or running, or walking uphill may lower the threshold at which the pain sets in.
Often added features put in an appearance. A heavy meal, cold air, wintry conditions, emotional upsets, arguments, situations where tensions mount, are all well-known factors that may initiate or aggravate symptoms. Even unpleasant dreams have been known to produce attacks during the night.
As a rule the pain rarely lasts more than a few minutes. The patient involuntarily ceases doing what he or she is engaged in, and tends to rest automatically The pain reaches maximum intensity quickly, and from the critical point, it reduces, along with the cessation of activity As the reduction in exercise occurs, the heart circulation gradually removes the metabolites producing the symptom at the cardiac interface. The pain reduces, and tends to die away.
Often there is a typical facial expression showing strain, fear or anxiety, and there may be pallor as blood drains from the countenance. Conversely some patients may flush and sweat, and the pulse rate and blood pressure may increase temporarily.
With the progression of time the patient’s condition inevitably deteriorates. Symptoms tend to come on more rapidly and with less and less initiating cause. Some patients even notice chest discomfort at complete rest. Attacks increase in severity and frequency. If there is a sudden escalation in attacks, it is a sign that a cardiac infarct may be imminent. Diagnosis. This is usually made by the doctor after a consideration of several factors. The patient’s history is the main feature indicating angina pectoris. However, the electrocardiogram (ECG) gives valuable diagnostic evidence in about 85 per cent of cases.
A series of tests may have to be taken before the telltale signs put in their appearance on the ECG tracing.
Sometimes, if a normal tracing is given (not uncommon in early cases at rest), mild exercise may subsequently show up the cardiac lesion. Often a stress test may reveal the disorder. This is a continuous ECG taken while the patient is vigorously exercising – often on a special machine.
Then, if further evidence is essential, coronary angiography may be carried out. This gives an X-ray picture of the arteries of the heart, and it may show a clear point where obstruction is occurring.
This is now widely used, particularly if corrective cardiac surgery is anticipated. The actual site of the narrowing of the cardiac vessels may be determined with considerable accuracy In males aged 30 years or more, angina is the most common cause of pain of this type. It is not so common in women. The physician must eliminate other possible causes before pinpointing a diagnosis.
Many highly strung people and those with neurotic tendencies often claim they have pain just about or under the left nipple area, and believe this is cardiac in nature. The discomfort they describe is often inconstant, may come on some time after activity, and may persist for many hours; it is often related to fatigue rather than exercise. Electrocardiograms are invariably normal.
Other common causes for pain in this general region are hiatus hernia (diagnosed more frequently these days with the use of endoscopy and more sophisticated and accurate X-ray equipment), gall-bladder disease, and lesions of the vertebral column. All can produce diagnostic problems for the doctor.
The treatment of angina has seen major improvements in recent times, both in the nature and variety of drugs available, as well as its practical (surgical) management. Indeed, it is still in the throes of a major medical revolution. Several new drugs have appeared and older medications have become available in newer and more acceptable forms.
Basically these have been used for many years. The most widely prescribed is glyceryl trinitrate (Anginine) in a 600 mcg tablet. This is slowly chewed and the active medication rapidly absorbed from the lining of the mouth. However, its beneficial effect lasts only a short time, perhaps 30 minutes or even less, so that further doses, often close together, are necessary. Anginine has a rapid onset of action, often within a couple of minutes. The product appears almost entirely devoid of toxic symptoms, and the dose may be repeated often. In fact, some angina patients take large quantities of this medication regularly and safely.
If activity is anticipated that is expected to cause pain, it is possible to suck a tablet under the tongue beforehand, and this will often effectively reduce the pain. Some patients find that the medication produces a severe headache (ranging from a dull throb to a “splitting headache” – this varies with the individual and his or her own pain threshold). Anginine is now available in an ointment form that is rubbed into the skin. It is given for patients who experience nocturnal angina.
A patch a little like a bandaid (but impregnated with medication) is placed on varying parts of the skin, and the drug is slowly absorbed over a number of hours. It is claimed to give a more even, regular input of the drug into the system, and may keep the patient pain-free for many consecutive hours. Occasionally skin rashes appear, but by moving the patch around each time a new one is applied. this can generally be minimised.
lsosorbide dinitrate (Isordil) is another way in which this medication may be taken, either in the form of 5 mg tablets that arc chewed (and absorbed through the mouth lining), or a 10 mg tablet that is swallowed. This has a much longer duration of action, and is more suitable for those with ongoing, frequent anginal chest pain. Also, a spray-on preparation (Nitro-Spray) is used with reasonable success.
Some may have heard about a product called amyl nitrate, a silk-covered glass capsule that was inhaled and gave immediate results. However, this has now been entirely replaced by the more modern methods of medication.
From propranolol (Inderal), the first of a new family called the beta-blockers, several drugs under the same banner have now been produced. These decrease the workload of the heart muscle, and lower the pulse rate, so that the heart is required to do less work under the same circumstances. The side effects are very minor. Newer beta-blockers are said to be cardio selective, indicating that they work directly on the heart fibres and have virtually no adverse effect on any other system. Heart patients will be familiar with many of these, such as propranolol, the original one (Inderal, Cardinol and others), metoprolol (Betaloc, Lopressor), alprenolol (Aptin, Betacard), atenolol (Tenormin). Some of these have a fairly long period of activity, up to eight hours or more, making twicea- day dosage the norm – much easier for the patient to remember.
Another valuable property of the betablockers is their ability to reduce the risk of death after a sudden heart attack, and to minimise the risk of a second infarct from taking place. Therefore, they are often given after a heart attack for this purpose, and it is claimed they lessen the risk of a reinfarction by 40 per cent.
Another family of drugs has also evolved, with the general description and title of Calcium Antagonists. Although they work in a different way from the others, their net effect is similar in that they reduce chest pain. In fact, they block the intake of calcium by the blood vessels, causing them to relax, lower blood pressure, and reduce the need of more blood by the heart muscle. They are often used instead of the beta-blockers, rarely together although both of these families may be used in conjunction with the nitrates. Many patients will recognise the names of the calcium antagonists, verapamil (Verpamil, Cordilox, Isoptin), nifedipine (Adalat), diltiazem (Cardizem), and felodipine (Plendil).