ANGINA Angina pectoris is severe chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm

of the coronary arteries. It may feel like pressure or a squeezing pain in the chest. It may feel like indigestion. One can also feel pain in their shoulders, arms, neck, jaw or back. Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries. There is a weak relationship between severity of pain and degree of oxygen deprivation in the heart muscle (i.e., there can be severe pain with little or no risk of a heart attack, and a heart attack can occur without pain).

Classification There are three types of angina: stable, unstable and variant Unstable angina is the most dangerous. It does not follow a pattern and can happen without physical exertion. It does not go away with rest or medicine. It is a sign that you could have a heart attack soon.

Stable angina Also known as effort angina, this refers to the more common understanding of angina related to myocardial ischemia.
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Typical presentations of stable angina is that of chest discomfort and associated symptoms precipitated by some activity (running, walking, etc.) with minimal or non-existent symptoms at rest. Symptoms typically abate several minutes following cessation of precipitating activities and resume when activity resumes. In this way, stable angina may be thought of as being similar to claudication symptoms. Unstable angina Unstable angina (UA) (also "crescendo angina;" this is a form of acute coronary syndrome) is defined as angina pectoris that changes or worsens. As these may herald myocardial infarction (a heart attack), they require urgent medical attention and are generally treated as a presumed heart attack. It has at least one of these three features: 1. it occurs at rest (or with minimal exertion), usually lasting >10 min; 2. it is severe and of new onset (i.e., within the prior 46 weeks); and/or 3. It occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously). UA may occur unpredictably at rest which may be a serious indicator of an impending heart attack. What differentiates stable angina from unstable angina (other than symptoms) is the pathophysiology of the atherosclerosis. The pathophysiology of unstable angina is the reduction of coronary flow due to transient platelet aggregation on apparently normal endothelium, coronary artery spasms or coronary thrombosis. The process starts with atherosclerosis, and when inflamed leads to an active plaque, which undergoes thrombosis and results in acute ischemia, which finally results in cell necrosis
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after calcium entry. Studies show that 64% of all unstable anginas occur between 10 PM and 8 AM when patients are at rest. In stable angina, the developing atheroma is protected with a fibrous cap. This cap (atherosclerotic plaque) may rupture in unstable angina, allowing blood clots to precipitate and further decrease the lumen of the coronary vessel. This explains why an unstable angina appears to be independent of activity. Microvascular angina Microvascular Angina or Angina Syndrome X is characterized by angina-like chest pain, but have different causes. The cause of Microvascular Angina is unknown, but it appears to be the result of poor function in the tiny blood vessels of the heart, arms and legs. Since microvascular angina isn't characterized by arterial blockages, it's harder to recognize and diagnose, but its prognosis is excellent. Signs and symptoms Most patients with angina complain of Chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain, and is due to the spinal level that receives visceral sensation from the
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heart simultaneously receiving cutaneous sensation from parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. In this case, the pulse rate and the blood pressure increases. Chest pain lasting only a few seconds is normally not angina. Myocardial ischemia comes about when the myocardia (the heart muscles) receive insufficient blood and oxygen to function normally either because of increased oxygen demand by the myocardia or by decreased supply to the myocardia.
This inadequate perfusion of blood and the resulting reduced

delivery of oxygen and nutrients is directly correlated to blocked or narrowed blood vessels.
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 Some

experience

"autonomic

symptoms"

(related

to

increased activity of the autonomic nervous system) such as nausea, vomiting and pallor.
Major risk factors for angina include cigarette smoking,

diabetes, high cholesterol, high blood pressure, sedentary lifestyle and family history of premature heart disease. A variant form of angina (Prinzmetal's angina) occurs in patients with normal coronary arteries or insignificant atherosclerosis. It is thought to be caused by spasms of the artery. It occurs more in younger women. Cause Major risk factors

Age ( 55 years for men, 65 for women) Cigarette smoking Diabetes mellitus (DM) Dyslipidemia Family History of premature Cardiovascular Disease (men <55 years, female <65) Hypertension (HTN) Kidney disease (microalbuminuria or GFR<60 mL/min) Obesity (BMI 30 kg/m2) Physical inactivity

Conditions that exacerbate or provoke angina Medications

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vasodilators excessive thyroid replacement vasoconstrictors polycythemia which thickens the blood causing it to slow its flow through the heart muscle

One study found that smokers with coronary artery disease had a significantly increased level of sympathetic nerve activity when compared to those without. This is in addition to increases in blood pressure, heart rate and peripheral vascular resistance associated with nicotine which may lead to recurrent angina attacks. Additionally, CDC reports that the risk of CHD, stroke, and PVD is reduced within 12 years of smoking cessation. In another study, it was found that after one year, the prevalence of angina in smoking men under 60 after an initial attack was 40% less in those who had quit smoking compared to those who continued. Studies have found that there are short term and long term benefits to smoking cessation.

Pathophysiology Angina results when there is an imbalance between the heart's oxygen demand and supply. This imbalance can result from an increase in demand (e.g. during exercise) without a proportional increase in supply (e.g. due to obstruction or atherosclerosis of the coronary arteries).

Suspected angina Hospital admission for people with the following symptoms, as they may have unstable angina: Pain at rest (which may occur at
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night), pain on minimal exertion, angina that seems to be progressing rapidly despite increasing medical treatment