Angina pectoris

Definition chest pain that is the product of transient myocardial ischemia.


Etiology artherosclerotic (narrow artery), hypercoagulation, supply of O2 & myocardial demand imbalance.
Pathogenesis Ischemia happens when there is demand and supply disbalance
1. When only demand is ( dynamic changes ) 

2. Supply is impaired, demand not 

3. Demand increase and supply decrease 

4. Demand & supply both ↑ - Heart effects & bad regulation. Bad factor accompany with each other. 

Main mechanism due to spasm of artery and transient hypercoagulation 1. Spasm
a. hyperactivity of receptor in large and middle sized coronary artery cause general spasm of coronary system. spasm of these large trunk cause in blood
and O2 supply 

b. Disbalance of and receptor - receptor dilate coronary system in stress condition 20 

c. Atherosclerotic plaque damage endothelium
2. Hypercoagulation - coagulation of artery depend on thrombocyte activation

Stable angina Unstable angina

1. Stable - due to dynamic spasm characterized by absence of stereotype-prolonged
- occlusion caused by atheroma ( not spasm ) 
 pain, severe, can occur in rest,
- 4 grades acc to tolerance to physical activity ( Canadian Cardiology Society decreased physical activities, need more tablets to relieve the pain.
)
 a. Progressive exertional / accelerated angina
- characterized by stereotypic characteristics, pain arises after a particular - patient > stable 

level of physical exertion is 
relieved by specific NG. 
 - duration of attack/ year: 15-20 

Ordinary physical activity does not cause angina, such as - tolerance to physical activity very short 

Grade 1 walking and climbing stairs. Angina with strenuous or rapid - NG not so effective 

or prolonged exertion at work or recreation b. New onset angina
Slight limitation of ordinary activity. Walking or climbing - suddenly appear 

stairs rapidly, walking uphill, walking or stair climbing after - can‘t predict the outcome 

meals, or in cold, or in wind, or under emotional stress, or c. Variant/ Prinzmetal angina
Grade 2 only during the few hours after awakening. Walking more - appear only at rest and physical activity don‘t provoke it
than two blocks on the level and climbing more than one 

flight of ordinary stairs at a normal pace and in normal - angina > prolonged 

conditions - > severe pain 

Marked limitation of ordinary physical activity. Walking - no absolute effect of NG
Grade 3 one or two blocks on the level and climbing one flight of
stairs in normal conditions and at normal pace
Inability to carry on any physical activity without
Grade 4
discomfort, anginal syndrome may be present at rest
- Decubitus angina – Due to changes of posture, increase preload to heart,
attack. 

- Noctural angina – This group is loss because majority of them dies. 

 Clinical Circumstances
A B C
Severity Develops in Develops in Develops
presence of the absence within 2 weeks
extracardiac of after acute
condition that extracardiac myocardial
intensifies condition infarction
myocardial (primary UA) (postinfarction
ischemia UA)
(secondary UA)
I New onset of IA IB IC
severe angina
or accelerated
angina; no rest
pain
II Angina at rest IIA IIB IIC
within past
month but not
within
preceding 48
hr (angina at
rest, subacute)
III Angina at rest IIIA IIIB Troponin IIIC
within 48 hr negative
(angina at rest, IIIB Troponin
acute) positive
Classification of unstable angina according E. Braunwald

Clinical symptoms - pain in constant situation 
 Progressive exertional angina Prinzmetal / variant angina
- Chest discomfort, heaviness, pressure, squeezing 
 Clinical Low risk The pain or discomfort:
- Radiate to the left shoulder & to both arms, ulnar surfaces & hand. 
 symptoms - Increased chest pain  Usually occurs
- It can also radiate to the back, neck, jaw, teeth & epigastrium. 
 frequency, severity, duration. 
 while resting and
- Pain when low blood supply (energetic disbalance) 
 - Chest pain provoked at lower during the night or
- In heart no pain receptor, only specific receptor baroreceptor, threshold. 
 early morning
chemoreceptor, mechanoreceptor 
 - New onset angina, <2 months. hours
- In ischemic zone, overactivity of receptor electrical function to brain 
  Are usually severe
reach thalamus and irradiate 
to cortex 
 -Intermediate risk  Can be relieved by
- pain is transient 
 - Rest angina. 
 taking medication
- Pain localised in the chest , substernal area 
 - Nocturnal chest pain. 

- Duration: never exceed 20-30 min normally 5-10 min, Duration of pain is - New onset angina, <2 weeks. 

>1 min & <20 min, pain less 
than 5 minutes is not angina pain 
 High risk
- Physical activity like walking, climbing, carrying heavy things, stress, ↑ - Prolonged rest angina. 

 eating volume cause SNS 
 - Cardiac failure, S3, new
- Nitroglycerin sublingual relieve pain in < 5 min at rest 
 systolic murmur, hypotension. 

- Irradiation to central part of the chest, left shoulder, scapula region, neck,
jaw, arm, hand till 4 & 5

- Character of pain: struggling, heaviness, squeezing, burning, sharp, and
localised pain which can be 
shown by finger, Pressing, aching. 


patho - Non occlusive thrombus –  Exposure to cold

platelet plug – overlying a weather
fissured atherosclerotic plaque.  Stress

  Medicines that
- Dynamic obstruction –spasm tighten or narrow
of coronary artery. 
 blood vessels
- Severe, organic luminal  Smoking
narrowing 
  Cocaine use
- Arterial inflammation leading
to thrombosis 

- Increase in myocardial O2
demand caused by tachycardia,
fever & thyrotoxicosis. 


Management 1. Grade 1 Tactic of management 


- only nitroglycerin before physical exertion - hospitalization 

- Nitroglycerin-sublingual,shortacting 
 - monitoring of BP 

- prevent the further atherosclerosis:-aspirin 
therapy, regular diet 
 - stop pain, by oral NG / opiode
- decrease cholesterol level: 
Statins-levastatin, lovastatin Derivatives of IV / NG IV under BP control 

fibric acids-clofibrate Probucal
Nicothinic acid
Bile acid sequestrants 
 - Metabolic therapy 

2. Grade 2 - stable condition, send to ward
- antianginal therapy. 
 with aspirin, give β blocker,
- β blockers, nitrate, Ca channels blockers with aspirin to diminish (Metaprolol, Athenolol) and
coagulation. tablets NG 

- beta blockers-proparanol and athenolol 
 - Concomitant conditions
- aspirin-75-80/daily 
 (tachycardia, hypertension,
- drugs that decrease cholesterol 
 diabetes mellitus) treated. 

- Ca channel blockers 
 - Glyceryl trinitrate - overcome
- prolonged nitrates 
 superimposed coronary artery
3. Grade 3 spasm. 

- Combined therapy (β-blockers & Ca) and 3 groups together (β-blockers, Ca - Low molecular weight heparin
& sublingual nitroglycerin). 
 - combination of heparin &
- If condition is worst, surgical treatment -tube catheter,ballon aspirin 

catheter,bypass surgery - Beta-blockers 

- aspirin 
 - Calcium antagonist.
- drugs that decrease cholesterol 
 (verapamil) 

 - metabolic drugs-riboxin 
 - Discharge after 10 days 

- change lifestyle - strict bed rest until

4. Grade 4
- combination of nitrates + beta blockers + Ca stabilization of coronary blood
channel blockers
- Metabolic therapy (mexidole). riboxin - surgical flow and oxygen 

treatment
- rest
Investigation
Pharmacological test
+ Positive effect
Nitroglycerin 

Β-blockers - propranolol, metoprolol, atenolol, nadolol, and timolol. 

Calcium antagonists 

+ Negative effect 

- Diperidamole and Curantile. Injection intravenously. - It will cause attack.
+ Cardiac catheterization with coronary arteriography - for direct visualization of the coronary arteries by injection radiographic contrast. used for coronary
artery disease. 

+ Cardioscintigraphy - thalium is injected into peripheral venous blood 

+ Pharmacological stress - injection of vasodilator - normal vessels are dilated. Abnormal vessels show 

ischemia.they cannot dilate.
Indications
- Angina refractory to medical therapy. 

- Strongly positive exercise test. 

- Angina occurring after myocardial 
infarction. 

- When the diagnosis of angina is uncertain. 

- to put diagnosis 

- to know grades of angina 

- checking of therapy effectiveness 

- to check ability of patient with M.I
Contraindications
- Myocardial infarction, fresh in 2 weeks 

- Transmural. 

- Unstable angina(new onset, stable, 
Prinzmetal) 

- Acute/ chronic resp failure 

- Acute/chronic cardiac failure 

- Stenosis of aortic valve, fever, disease of 
joint
Stress test (provocation test) 

- Allergy for drug. 

- ↑ BP (180/110), tachycardia 

- Stroke and surgical operation of brain. 

- any varaiant of acute fresh inflammation 

- aneurysm of the heart 

- serious arrythmia 

- diseases of the joint 

- episodes of thrombophlebitis
- don‘t need to wait demand supply disbalance 

 - e.g. step test, ergometry (walking, cycling), treadmill 

- Provocation BP X HR at moment of investigation 



 Age Watt ( bpm )

20-30 170

 30-40 150
40-50 150
50-60 140

- physical work done step by step in 2 variants

-non stop – increasing in mechanical load 

-1 min of rest after each step for old people

- record ECG in next few minutes 2,3,4,5,10 


- some people can reach submax level without changes in ECG 

- inflammatory changes / dystrophy process in the heart check in ECG and clinical signs 

1. Indication
- give artificial condition to test the heart function before angina occurs
2. Contraindication
- stress test for people > 60 yrs old not done 

- no leg, weakness 

3. Evaluation of results of stress test
Clinical prove of angina :
- if patient stop before or have sudden chest pain provoked by testing 

- if BP < 25-30% stop test and if BP > 220/110 stop the test 

- sensitivity of stress test, may be false and patient don‘t show problem in test 

During stress test 

-direct signs of ischemia-classical pain episode, dyspnea, dizziness, cold sweat, decrease blood pressure 

-ECG
- ST depression 

- abnormal shape of QRS complex 

- appearance of transient pathological Q wave 

- episode of transient ventricular arrhythmia 
Stress echocardiography - based on principles as stress radionuclide ventriculography but an
echocardiograph is used to produce the images of wall motion abnormalities. 


General management 1. Nitrates – sublingual/IV

- nitroglycerin sublingual 

- Dinitrate isosorbide – tablet 

- NGinIV 

- glyceryl trinitrate (GTN) spray /sublingual tabs, oral nitrate e.g. isosorbide mononitrate 

2. β – blockers
- Propanolol 

- selective group, Atenolol 

 - Nebivalol 

3.Ca channel blocker
- Verapamil, Diltiazem 

- Ca antagonists: amlodipine 

- Alteration of life style: stop smoking, encourage exercise, weight loss. 

- Modify risk factors: diabetes, hypertension. 

- Aspirin 

- adding a K+ channel activator, e.g. nicorandil per os. 

Indication of surgical treatment
- 3 class angina pectoris 

- stenosis of > 75% of 3 coronary vessel 

- no effect on drug 

- patients who remain symptomatic despite optimal medical therapy & whose disease is not suitable for 
percutaneous
transluminal coronary angioplasty