Angina Pectoris: Causes, Symptoms, and Treatment

Angina Pectoris

• This is a condition with intense substernal chest pain.
• The pain increases because of exercise, emotional stress, and cold temperatures.
• Pain is referred to the left shoulder, neck, and jaw with heaviness in a clenched fist over the precordium (Levine's sign)
• Myocardial demand exceeds the ability of compromised coronary circulation leading to classic/effort angina.
• Variant/Prinzmetal's angina can also occur, alongside unstable angina or now termed acute coronary syndrome

Angina Pectoris Treatment

• Beta-adrenergic receptor blockers (decreased heart rate) are used.
• Ranolazine (Elliott says no outcome data to support use)
• Nitrates and calcium-channel blockers can be used as treatment
• Aspirin is also an option
• Angiography and percutaneous coronary intervention (angioplasty) are short term, and coronary artery bypass grafting are said to give best long term benefits.

Angina Pectoris Additional Info

• May manifest differently in males (chest pain) and females (chest discomfort).
• Diagnosis is performed by ECG with 50% accuracy, and an exercise stress test may give a good indication of functional cardiac reserve
• Nuclear medicine, 2-dimensional echocardiography, MRI, and portion emission tomography can be used.
• Angiography is the gold standard, but is risky and expensive.

Vasospastic Angina

• This is non-exertional and occurs at rest.
• It pertains to the hyperreactive vasospasm of coronary vascular smooth cells and nitric oxide deficiency
• Younger patients with fewer traditional cardiovascular risk factors are affected most
• Rapidly reversible with nitrates and calcium channel blockers.
• Vasospasm after an injection of ergonovine by coronary angiography, and nitrate responsiveness could ensue as a result.
• Diagnosed by observing ECG changes (ST segment elevation).

Myocardial Infarction

• Flow is greatly reduced after a coronary artery occlusion in this event
• Affected cardiac myocytes are ischemic and dysfunctional, and become non-functional

Pulmonary Edema

• Can occur during myocardial infarction, where blood is not pumped efficiently into the systemic circulation contributing diminished cardiac output and decreased blood flow.

Ventricular Fibrillation

• Caused by hyperkalemia, current of injury, and excessively long path length for action potential conduction.

Rupture of the Heart

• As cardiac muscle fibers degenerate with myocardial infarction the heart wall thins and increases systolic stretch.
• Ventricular wall ruptures, leaks blood into the pericardium, leading to cardiac tamponade because of excess sympathetic activity.

Aging Heart Pathology

• Features Fewer myocytes increased CT, amyloid deposition, decreased LC chamber size, valvular changes, lambl's excrescences.
• Brown atrophy, epicardial fat, and basophilic degeneration.

Congestive Heart Failure

• A common and progressive condition
• Pumping function doesn't meet oxygen demands, which is precipitated by hemodynamic stress

Cardiac Hypertrophy

• Involves increases in myocyte size, heart size, and weight.
• This is because of sustained increase in mechanical work due to pressure or volume overload commonly because of systemic hypertension, aortic stenosis, and trophic signals
• Patterns of cardiac hypertrophy include pressure or volume overload hypertrophy.
• Can be healthy from exercise that promotes potentially physiological hypertrophy

Forward vs Backward Heart Failure

• Forward failure shows decreased cardiac output with tissue perfusion.
• While backward failure presents issues with increased salt and water retention, and systemic venous congestion, and pooling venous blood and PE.

Congestive Heart Failure Types

• Systolic failure
• Diastolic failure.
• Ischemic heart disease causes both, backing up blood in pulmonary circulation, and causing heart hypertrophy and dilation of the left atrium Hypertension and mitral valve disease Myocardial disease also brings about an inadequate perfusion leading to organ dysfunction

Right Sided Congestive Heart Failure

Causes increased pulmonary hypertension and hypertrophy with dilation which burdens the right heart leading to increased risk of martial fibrillation with pulmonary congestion, edema with activated kidney to activate the renin-angiotensin-aldosterone system This is most commonly caused by left sided heart failure

Ischemic Heart Disease

Characterized by wavy fibers, myocyte vacuolization, and granulation tissue seven to ten days after MI.

Coronary Artery Disease (CAD) or (IHD)

Myocardial infarction can occur with ischemia with the result of necrosis coupled with angina pectoris, and sudden cardiac death

Patterns of Infarction: Collateral Circulation

Intracoronary anastomosis will enlarge over time when the coronary is obstructed and will expand into normal territories

Patterns of STEMI, NSTEMI and Microinfarction

• STEMI, Occlusion of the epicardial vessels can result in necrosis of the ventral wall. Associated with chronic coronary atherosclerosis, acute plaque change, and superimposed thrombosis.
• NSTEMI, the inner third of the ventricular wall, areas from plaque distribution, prolonged severe reaction with blood pressure.
• Microinfarction, the involves smaller intra mural vessels with sudden cardiac death, also known as takotsubo The leading cause death in USA

Chronic Ischemic Cardiovascular Disease

• Can be from cardiomegaly and the LV hypertrophy dilation
• Coronary atherosclerosis which happens with pathway thickening of mural endocardium

Cardiomyopothy

Progressive congested heart failure results when the patient has accumulated ischemic myocardial damage with responses

Chronic Ischemic Cardiovascular Disease/ CardiOmypothy Treatment

Troponin can diagnoses the condition and you need full dose NSAIDS to treat for two weeks, and if the NSAIDS do not treat switch the patient to glucorticords otherwise early MI needs to be treated with aspirin Patient will be in full dose if they have previous prior MI, previous coronary artery intervention, post infraction which is severely bad with obstructive CAD, or cardiac recipients When patients are experiencing pericardial fluid accumulation, there is inflammation and types include; Pericardial effusion, Hemopericardium, Purulent pericarditis which could result in tamponade, or healed pericarditis. Serous pericarditis is from Constrictive pericarditits when there is being distended by and Fibrinous; Pain where are loud and can be by