Angina: nothing to do with Vagina

Angina Pectoris is defined as a recurring pain or discomfort in the chest area that often occurs when some part of the heart does not receive enough blood. Angina is a very common clinical presentation in individuals who have disease in their coronary vessels. The coronary vessels are narrowed or blocked by plaque and do not allow for blood to get to that part of the heart. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. Statistics reveal that close to 7 million American suffer from angina and countless more do not even know if they have it. Each year close to half a million new cases are diagnosed. The common condition affects nearly ¼ individuals over the age of 55. Each year, there are more than 1 million cases of recurrent acute angina, with a morality rate of close to 40%. In addition, there are a significant number of individual who die suddenly and have no symptoms. No race or ethnic groups are immune from coronary artery disease. angina pectoris is far more common in women than men. In addition, angina in women can present in an atypical fashion. The pain may not be in the chest area and the pain may have a different quality.

Angina basically means chest pain because the heart does not get enough oxygen. When the blood vessels (coronary vessel) which supply the heart develop plaques (atherosclerosis), they narrow and sometimes completely close off. This causes the distal part of the heart does not receive any more blood and individuals will develop chest pain. Initially when the coronary disease is mild the angina will occur during exercise, eating heavy meals, extreme heat or stress. As the coronary disease worsens, the angina will come on with minimal work and may even occur at rest.

Angina indicates that the heart is not getting enough oxygen. It occurs when there is coronary artery disease. Some people may get angina while performing exercise and others may develop it during rest. For those who get episodic angina, the heart muscle is not damaged and the condition is reversible with treatment. In those individual with chest pain at rest, there is serious blockage of the coronary vessels and something needs to be done about it. Angina left alone can only get worse, unless one changes the lifestyle and takes the medications. Remember angina is a warning sign that the heart is not getting enough oxygen and the heart will not tolerate this forever. Continuing angina just goes on to kill the heart muscle. When the angina gets worse, a heart attack is the next step. When angina gets severe and the pain does not stop despite the medications, urgent hospital admission is necessary. In all individuals in whom stable periodic angina changes to more frequent episodes of longer lasting chest pain, one should be concerned and see a doctor

Angina is always associated with pain but the location of the pain is quite variable. The pain is squeezing in nature and may radiate to the left arm, jaws, neck or the back. In some cases the pain is on the right side of the chest and into the upper abdomen. The pain is usually described as a pressure, heaviness, squeezing, burning, or a choking sensation. Angina can last from a few seconds to a couple of minutes and is relieved by nitroglycerin. The pain of angina does not change with position, breathing, or cough.

Because of the seriousness of the disorder, anytime someone has pain in the chest, it is ascribed to angina. This is not true. Angina is classically chest pain associated with the heart. There are other causes of chest pain that can mimic angina. These include disorders of the esophagus, pneumonias, inflammation of pericardium and pleura or pain in the ribs. However, this may not always be obvious and it is the physicians responsibility to determine what is the causing the pain. Ignoring angina can be devastating for the patient and the physician’s career.

Both the physician and the individual should know and understand what is stable and what is unstable angina. Typically angina occurs in a regular pattern. The patient can sense the pain coming and the pain is similar to previous episodes. The level of activity that provokes this angina is familiar to the individual and in most cases the pain dissipates after taking nitroglycerin- this is stable angina. In most cases, nothing serious happens. In unstable angina, the pain comes on suddenly even at rest and does not dissipate with rest or nitroglycerin. The chest pain becomes unpredictable and fails to respond to the normal doses of nitroglycerin. The individual may also develop nausea, vomiting and may sweat profusely. This is a dangerous condition and needs urgent evaluation and treatment. When individuals develop this condition, the chance of a heart attack is imminent.

Today there are several classifications of angina. The Canadian and the Americans both have a class to grade angina: The Canadian Cardiovascular Society grading scale is used for classification of angina severity, as follows: - Class I - Angina only during strenuous or prolonged physical activity - Class II - Slight limitation, with angina only during vigorous physical activity - Class III - Symptoms with everyday living activities, ie, moderate limitation - Class IV - Inability to perform any activity without angina or angina at rest, ie, severe limitation Unstable angina is defined as new-onset angina (ie, within 2 mo of initial presentation) of at least class III severity, significant recent increase in frequency and severity of angina, or angina at rest

The diagnosis of angina is made on the history and clinical presentation. However, in many cases, this suspicion of angina has to be confirmed by some type of tests. The tests to confirm angina are: ECG: The ECG may indicate that the either there is heart damage or that heart damage has occurred in the past. ECG is most beneficial when the individual is actually having the chest pain. In many individuals who have no chest pain, the ECG may not reveal anything abnormal. Stress test: If there is strong suspicion of coronary artery disease, a stress test is done. This simply involves exercising the individual under controlled conditions and monitoring him. There are numerous types of stress tests and in many cases; the stress test may not be conclusive. Angiogram: the gold standard to determine if there is coronary artery disease is the angiogram. Basically, a dye is injected and the anatomy of the heart is imaged. This test can tell if the heart is beating fine and if there is any coronary artery disease. The reason this test is not always the first choice is because it is invasive and has minor complications associated with it. CT scan: Today, all over America, electron beam tomography has been introduced to screen for coronary artery disease. The technique is excellent but expensive. The test takes about 10 minutes and one can go home soon after.

To treat angina, one must control the risk factors. This includes:

To improve the prognosis, it is essential that one change the lifestyle. One should adhere to these changes, otherwise angina will recur. The best preventive measures one can take include - start an exercise program - stop smoking - decrease alcohol consumption - avoid stressful situation - avoid heavy and fatty meals

The best treatment of angina is drug therapy. The most common group of drugs used to treat angina is nitroglycerines. Nitroglycerin is available in various formulations. It can be taken by mouth, placed underneath the tongue and can even be given intravenously. Nitroglycerin has the ability to open up (dilate) blood vessel and allows more blood to the heart. Nitroglycerin is usually taken when one feels the chest pain coming. A tablet is placed underneath the tongue and within a few minutes the pain will disappear. In some cases, two tablets may be required. Nitroglycerin formulations are also available as an oral pill which must be taken 2-3 times a day. Beta blockers have been used to treat coronary disease for decades. They act by decreasing the work of the heart and thus decrease oxygen utilization. Unfortunately they work in the long term and do not work immediately, like nitroglycerin. Beta blockers have to be taken every day and have a few side effects like a decrease in libido. Calcium channel blockers are very effective in the treatment of angina, but like the beta blockers they have to be taken daily. They do not work immediately and act by decreasing the work of the heart and opening up the blood vessels. If your physician has any clinical acumen, he will also start you on a low dose of aspirin. It has been known that aspirin is beneficial in prevent heart attacks and also slows down the build up of plaque. There are other drugs like aspirin available today but they are far more expensive and are no more effective than aspirin.

In some individuals, the medications do not help and the chest pain continues and becomes more intense. In these individuals, the risk of a heart attack is ever present and other options are available. The gold standard method to determine which and how many blood vessels in the heart are narrowed is the cardiac angiogram. In these individuals an angiogram is required and if the blood vessel is narrow or blocked it can be opened up by ballooning and then placing a stent to prevent recurrence of blockage. This will instantly relieve pain and is generally the first interventional choice.

: Sometimes the coronary artery disease is too diffuse and not amenable to angioplasty. In such cases, surgery is the next best option. There are various surgical procedures to correct coronary artery disease and they all involve opening the chest. Surgery is not a simple undertaking and complications are plentiful (despite what the surgeons claim). The recovery is long and many individuals are unable to return to their former job. Today, there are some laser techniques which can help increase blood flow to the heart. The technique of transmyocardial revascularization has been around for 10 years and yet there is no firm data if it actually does anything.

All individuals must understand that coronary artery disease (like our age) is progressive and there is no cure. All treatments for this disease are palliative and even with the best medications and surgery, the condition will progress. Since there is no cure, the best thing to do is prevent it from getting worse. Preventive measures require common sense and a lot of hard work to maintain the rigid life style changes. These include: - resume a regular exercise program - try and lose weight if one is obese - stop smoking - control the blood sugar - avoid stress - monitor blood pressure - carry NTG all the time - control fat in your diet

For those with mild episodic angina, the outlook is good. For those with moderate to severe angina, one better watch out.