It is defined as paroxysmal precordial pain of short duration due to transient (temporary) myocardial ischaemia.
Main symptom is pain which has the following characters—
• Site—central, retrosternal chest.
• Character—stabbing or squeezing or constricting.
• Radiation—lower jaw, neck, inner-side of the left arm up to the finger.
• Precipitated by exertion, eating or emotion (3 E).
• Relieved by rest and nitroglycerine.
• Duration—5–10 minutes (<1/2 hour).
Usually no definitive physical sign.
Types of Angina Pectoris
• Stable angina or classical angina see as above).
• Unstable angina—It is characterized by angina of new onset or rapidly worsening angina, angina at rest or minimal activity. It is more severe, lasting for longer duration, occurs more frequently, not improved by rest or nitroglycerine. It is due to rupture, fissuring or ulceration
of an atherosclerotic plaque or thrombus. ECG shows transient ST, T changes (depression) but enzymes are normal. May cause MI in 10–20% cases.
• Prinzmetal’s angina—It occurs at rest without any provocating factor, usually in the early morning. More common in female. It occurs due to coronary artery spasm. ECG shows STelevation rather than depression during pain.
• Decubitus angina—It occurs when patient lies down due to impaired left ventricular function.
1. ECG is often normal. During attack—ST-depression, T-inversion.
2. Chest X-ray.
5. Coronary arteriography.
6. Other stress testing—
–– Myocardial perfusion scan.
–– Stress echocardiography
–– Transthoracic echocardiography.
7. For risk factor—Fasting lipid profile and blood sugar.
Tretament of Angina Pectoris
During acute attack—
• Sublingual glyceryl trinitrate (GTN) administered from a metered-dose aerosol or as tablet
allowed to dissolve under the tongue and retained in the mouth will usually relieve an attack
of angina in 2–3 minutes.
• If no response, it can be repeated. But if still no response, myocardial infarction should be
Prevention of further attack—
1. Antiplatelet therapy—low-dose (75–150 mg) aspirin, clopidogrel (75 mg daily).
2. Antianginal drugs—
–– To prevent angina pain—oral nitrates, such as isosorbide dinitrate (10–20 mg 8 hourly), isosorbide mononitrate (20–60 mg once or twice a day) can be given by mouth.
–– Other drugs—Beta-blocker (atenolol, metoprolol, bisoprolol). Calcium antagonists (nifedipine, nicardipine, verapamil and diltiazem), potassium channel activators like nicorandil may be used.
–– If recurrent or persistent pain, coronary angiogram should be done. If coronary artery blockage, then stenting or percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG) may be required.
3. Risk factors should be controlled:
–– Smoking must be stopped.
–– Reduction of weight, if obese.
–– Regular exercise, at least for 30 minutes daily.
–– Avoid alcohol intake.
–– Control of hypertension and diabetes mellitus.
–– Lipid lowering drugs—atorvastatin, rosuvastatin.
–– Avoidance of anxiety, tension, and depression.
–– Lifestyle modification.
Treatment of Unstable Angina
• Complete bed rest, oxygen.
• Sedation, if needed.
• Aspirin or clopidogrel.
• Calcium channel blocker.
• Heparin—LMW heparin (enoxaparin S/C) for 5–7 days.
• If pain persists, nitroglycerine infusion.
• If all measures fail, urgent coronary angiography and revuscularisation, if necessary.