ANGINA PECTORIS IN FAMILY PRACTICE
Pankaj K Mehta, Reena Mehta
Family Physicians, Kalachowki, Mumbai
Chest pain is a frequent presenting complaint. To the patient its significance is usually more ominous than that of other symptoms; he is apprehensive and suspects whether it is "heart attack". The major concern of the physician is therefore to establish or exclude chest pain of cardiac origin, which can cause sudden death.
There are about one dozen causes of chest pain but with proper elicitation of history, supplemented with systematic physical examination, one can narrow down the diagnosis to one or two.
The following characteristics of chest pain must be identified in each and every case:
1. Location (origin and radiation)
2. Quality (sharp, dull etc.)
3. Quantity (severity and duration in minutes)
4. Chronology (periodicity to date)
5. Setting in which pain occurs
6. Aggravating and relieving factors
7. Associated symptoms (dyspnoea, cough, sweating etc.)
1. Angina Pectoris (stable) : vide infra.
2. Unstable angina : vide infra.
3. Myocardial infarction : Pain occurs without any visible cause, usually during rest at night, patient is restless, pain lasting for half an hour or more, sublingual nitrate has no relief on pain. Autonomic disturbances are common and marked (patient has profuse sweating, nausea or vomiting, shock may follow soon). Pulse may be shallow, rapid and irregular. Blood pressure has a tendency to fall and there are characteristic changes in ECG and enzymes.
4. Pericarditis : Pain, usually on precordium, sharp, lasting several hours to days, aggravated by breathing, coughing, swallowing and lying flat. Sitting up relieves it. There is pericardial rub and local tenderness. ECG will show ST elevated with concavity upwards and inverted T may be seen.
5. Pulmonary embolism : It must be suspected in post-operative, post-traumatic or post-partum patients confined to bed. Patients complain of severe, central chest pain, associated with severe cough, breathlessness and marked cyanosis. There may be haemoptysis. ECG may show S1 Q3 T3 pattern. X-ray may show pneumonia like patch or may be normal. Ventilation - perfusion lung scan may pick up the diagnosis.
6. Chest pain related to food : Retrosternal pain; of burning quality, aggravated by lying flat or bending forward after food, relieved by sitting up and antacids (and also by nitrates!), it suggests oesophagitis or hiatus hernia.
7. Chest wall pain : Costochondritis or musculoskeletal pains are dull aches lasting for few seconds to several hours and days, aggravated by movements like turning, twisting, deep breathing or movements of shoulder and arm associated with local tenderness. It is relieved by analgesics and not by nitroglycerine.
8. Cervical spondylosis : Pain of cervical spondylosis radiating to left arm and chest may mimic cardiac pain but proper history and aggravation of pain in certain neck movements favours spondylosis.
9. Anxiety neurosis : It is common in women and young men. Pain is usually felt in left inframammary area, dull ache or soreness with stabbing or shooting pain, provoked by worry, emotional tension and fatigue associated with deep sighing respiration and choking feeling in throat. It is relieved by reassurance and tranquilizers and not by nitroglycerine.
Angina pectoris is a choking or constricting chest pain or discomfort, which comes on with exertion, relieved by rest or nitroglycerine, and is due to myocardial ischaemia. Suspect angina whenever:
1. Pain is experienced retrosternally (tie - area) or over precordium along with or without radiation to left shoulder, medial aspect of left arm and rarely left jaw, throat, teeth, neck or epigastrium. (Any pain below the jaw and above the umbilicus think of angina!).
2. Pain appears on exertion and disappears on rest or with sublingual glyceryl trinitrate or sorbitrate. It is important to stress that angina is a bedside clinical entity, diagnosed mainly by history taking. "Resting" ECG is plump normal in more than 60% of cases. This disease is suspected in a patient who has following risk factors.
1. Male gender usually more than 40-45 years of age.
2. Strong family history of close relatives (father, mother, brother and sister) getting heart attack below the age of 55 years.
4. Long standing diabetes
5. Long standing hypertension
6. Hyperlipidaemia, Hyperuricaemia
8. Sedentary life with tension and overwork (Type A personality)
Often the patient complains of discomfort in chest and not "pain" and he may label it as "gas" or "acidity". A high degree of suspicion is required to arrive at a proper diagnosis. The pain or discomfort comes on when the patient is "hurrying" and not "walking slow". Carrying a heavy handbag on the road or heavy luggage at airport often brings about the pain. It is also felt on climbing the staircase, especially the high steps of railway station. The pain or discomfort comes more often if the patient walks immediately after having a large meal or walking in cold weather. The pain may be brought on or exacerbated by emotional upset. This pain always subsides within few minutes of taking rest or sucking a tablet of Glyceryl trinitrate under the tongue.
1. Of attacks - Glyceryl trinitrate (GTN) 0.6 mg (Angised or Enjee), or isosorbide dinitrate 5 mg (sorbitrate) sublingually, or nitrate spray in a measured dose of 400 mg provided BP is normal or high. Effect starts in 3 to 5 minutes and its action lasts for 20 to 40 minutes. Contraindicated in patients with glaucoma and hypotension i.e. BP < 90/60 mm. of Hg. Buccal nitrates placed between upper lip and gum has rapid onset of action.
2. Prevention of attacks - Choice of therapy (medical) or revascularisation depends on response to anti ischaemic medications and risk of further cardiac events as judged by coronary angiography and evaluation of myocardial function.
Since the patient can live for a number of years and the disease will last lifetime, he should be made to understand the disease.
Apart from prescribing short or long acting nitrates, following points are also important.
1. Advise weight reduction.
2. To stop smoking completely and permanently.
3. To stop excessive drinking.
4. Adequate control of diabetes, hypertension and hyperlipidaemia.
5. Correction of disorders which increase myocardial oxygen demand such as anaemia and hyperthyroidism, if present.
6. Avoid fried fatty food. Avoid excessive carbohydrates.
7. Avoid walking for at least one hour after meal.
8. Bedrest not essential unless frequent attacks. Moderate exercise, which doesn’t cause pain or dyspnoea, allowed.
9. Less number of hours of work. Longer hours of sleep or rest, regular free weekends and vacations.
10. Avoid excessive tea, coffee and tobacco.
11. Practice relaxation techniques by yoga, self-hypnosis etc.
Apart from short and long acting nitrates, betablockers are the second group of drugs, which should be used in every case of angina pectoris Contraindications are cardiac failure, heart blocks, severe bradycardia, bronchial asthma, diabetes and peripheral vascular insufficiency. Betablockers are ideal for patients having concomitant, hypertension, migraine or anxiety with palpitations.
Usual dose is 20 to 40 mg of propranolol three times a day or 25 to 100 mg atenolol once a day.
Calcium channel blockers, like verapamil (40-80 mg t.d.s.), nifedipine (10-20 mg t.d.s.). nicardipine (10-20 mg t.d.s.) or diltiazem (30 mg - 60 mg t.d.s.) are also useful anti-anginal drugs. Aspirin 100 to 300 mg is advisable to prevent infarction.
It implies that 1) the angina has started or has increased within the previous 60 days; 2) the pain may occur at rest without obvious provoking factors; 3) it may last longer than 10 minutes; 4) nitroglycerine may offer no relief or incomplete relief and 5) there is no ECG change or enzyme evidence of myocardial infarction. The distinction between stable and unstable angina is useful since the prognosis and management strategies are different for the two conditions. Patients with unstable angina are at a much higher risk of early myocardial infarction and early death. They need aggressive therapy and various investigations, including coronary angiography to assess need and feasibility of coronary revascularisation. Heparin 5000 SC BD or Low molecular wt. Heparin SC BD x 10
Nitroderm patch BP can be applied provided BP is normal or High. Or Nitroglycerin IV microdrip can be started and the dose of 3-10 drops/min depending upon BP. Always keep BP > 90/60.
ANGINA EQUIVALENT OR ATYPICAL FORMS OF ANGINA
1. Pain may start in one of the sites of radiation and may be confined to that area e.g. only the left wrist, left sided lower molars, left shoulder.
2. Dyspnoea, with or without angina and exhaustion.
3. Episodic or chronic fatigue and exhaustion due to reduced cardiac output.
4. Sweating and nausea or vomiting because of severe pain and autonomic disturbances.
5. Prinzmetal’s angina : It is a form of angina pectoris, where anginal pain occurs at rest, usually at night, are of longer duration and of more severity associated with ST elevation (as opposed to ST depression seen in myocardial ischaemia) on ECG or Holter monitoring. ST elevation becomes isoelectric after sublingual nitrates in contrast to unstable angina or myocardial infarction. Coronary vasospasm accounts for the episodes. Beta-blockers are contraindicated in this condition.
Role of Modern Investigations
It is wiser to detect angina early and ask for investigations and revascularisation procedures, than to wait till an infarct develops. Holter monitoring, computerized stress test (CST) and nuclear cardiac studies would not only confirm the diagnosis of angina in difficult cases, but ideally should be done in every case of angina. This is because if a patient is found to have ‘grossly’ abnormal result with the above tests, he should undergo these ‘risky’ investigation of "coronary angiography" to decide if he needs coronary bypass surgery or other revascularisation procedure. At the same time if the patient can not afford the heavy cost or does not wish to undergo surgery, there is no point in spending on stress test and coronary angiography. Leave him alone on medical treatment.