Angina pectoris is the most common form of coronary heart disease. It occurs as a consequence of the thickening of a plaque inside the coronary arteries called atherosclerosis. This triggers an imbalance between myocardial oxygen supply and demand.
It manifests itself by pain in the precordial region ranging from slight pressure to intense pain in the center of the chest. It can also present as pain radiating to the shoulders, arms, neck, jaw, and even back, as well as sweating, nausea, abdominal pain, dyspnea, and syncope.
Less frequently it presents with epigastric pain, indigestion-like symptoms, or dyspnea. These atypical symptoms are more common in elderly patients, women, and patients with diabetes mellitus, chronic kidney disease, or dementia.
Anginal pain can have the following forms of presentation:
· Prolonged anginal pain (> 20 min) at rest
· New-onset (de novo) angina (Canadian Cardiovascular Society Class II or III.
· Recent destabilization of previously stable angina with features of at least class III angina (crescendo angina)
· Acute post-MI angina
How to treat angina pectoris
It involves a series of measures which include lifestyle modification, drug treatment, surgery and rehabilitation.
Lifestyle
Follow a healthy diet in order to prevent obesity, high cholesterol and blood pressure, avoid tobacco consumption, practice physical exercise daily, avoid situations that increase the level of stress.
Pharmacotherapy
The objective of anti-ischemic pharmacological treatment is to decrease myocardial oxygen demand and / or increase oxygen delivery to the myocardium. The most used therapy consists of the use of nitrates, beta blockers, calcium antagonists, oxygen among others.
Nitrates
It is the most common therapy used in the treatment of angina. These produce a decrease in the consumption of oxygen by the muscle and an increase in the blood supply to the heart through the relaxation and dilation of the blood vessels.
They are used to alleviate episodes of chest pain or prevent its appearance. They can be used to control blood pressure and decrease symptoms in the presence of heart failure.
Beta-blockers
They delay or prevent the onset of angina, their mechanism of action is through the reduction of myocardial oxygen consumption by reducing blood pressure, heart rate and myocardial contractility. They reduce the risk of progression to myocardial infarction.
Calcium antagonists
They are vasodilator drugs and some of them also lower blood pressure. They are effective in reducing pain and increasing the supply of blood and oxygen to the heart, but have no effect on progression to heart attack or death. They are used in those patients where beta-blockers are contraindicated.
Analgesia
It is used in those cases where precordial pain persists after adequate anti-ischemic treatment until definitive treatment is established. The use of intravenous morphine is recommended. The only non-steroidal anti-inflammatory drug allowed is aspirin, since these increase mortality and the incidence of myocardial infarction and cardiac muscle rupture.
Oxygen
The use of oxygen is controversial, recent studies have shown the harmful effects of reactive oxygen species (free radicals) in addition to producing systemic vasoconstriction and coronary blood vessels.
However, it is indicated in patients with oxygen saturation <90%, respiratory distress, or other high risk of developing hypoxemia.
Aortic compulsion balloon
Contrapulsion can be used for the treatment of severe and persistent ischemia despite intensive medical management especially in patients awaiting invasive angiography and revascularization therapy. It reduces myocardial oxygen consumption and increases coronary perfusion.
Surgical treatment
When pharmacological treatment does not control angina, other invasive procedures are usually necessary. Among them the two most common we have:
Angioplasty
It consists of the dilation of the blocked or narrowed coronary arteries. It can improve blood flow and prevent a heart attack. Sometimes a stent (cylindrical metal mesh) is placed inside the artery to keep the vessel patent after the procedure.
Coronary artery bypass surgery
Arteries or veins from other parts of the body are used to restore blood flow that is not provided by the blocked coronary arteries. Bypass surgery improves blood flow to the heart, relieves chest pain, and can prevent a heart attack.
Preventive treatment
It is common for patients with a history of episodes of angina to undergo preventive treatment with lipid- lowering drugs to lower cholesterol levels. Antihypertensive, to reduce high blood pressure. Antiplatelets, such as acetylsalicylic acid, to prevent the formation of blood clots produced by platelets. And anticoagulants to prevent blood clots from forming in the arteries.
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