Angina

Chest pain due to lack of adequate blood supply to the heart muscle is Angina. Not all chest pains are angina and at the same time, all angina will not cause chest pain. The Cardiologist will be able to tell whether a patient’s description of chest pain is anginal or noncardiac. How does he decide this? Let’s find out the typical descriptions of cardiac and non-cardiac chest pains.

how cardiac patient describes Angina

I am comfortable at rest. I am able to do all my day to day activity slowly without any problem. Previously I was able to walk briskly for 30 minutes/able to play 3 sets of game/able to climb 3 flights of stairs without any problems. But, since last few days/weeks I am having difficulties in doing these works. After a few minutes of heavy work, I will have chest tightness, chest heaviness as if there is a heavy stone over the chest. I will feel mild suffocation or breathing difficulty. I will have to slow down or stop. But if I stop, within a few minutes I will feel light, my chest tightness is resolved and again I will be able to carry out my work. If I go fast or carry heavyweight, this chest discomfort will start earlier. If I do not stop, it will keep on increasing.

Some patient may complain of this as chest pain, some may use words like Gabhraman, Chest heaviness, heartburn or just tiredness. This Pain like feeling is central, deep and may radiate to left arm, neck or the jaw. Left-arm pain is also related to his exertion and not continuous. The patient is comfortable at rest.

how non cardiac chest pain patient describes his pain

I am comfortable at exercise and having pain at rest. I am having episodes of pain, which is sharp and shooting like, occurring at a particular point lasting for a few seconds. Or, Pain is dull, diffuse, continuous and lasting for many hours and with that patient is able to continue his work. I am having pain on deep breathing or coughing. It is like a catch. Chest movement or torso movement relieves my pain. I am able to do all my exercise without any pain.

heart attack patients description

Anginal type of pain occurring at rest is suggestive of a heart attack. Severe chest pain with severe perspiration, chest pain with giddiness, vomiting, breathlessness are suggestive of severe cardiac problem. Remember, a heart attack can be silent too.

These descriptions are not absolute and may have many overlaps. And, in case of any unusual symptoms, you should consult a physician immediately and clear your doubts.

How a lack of blood supply causes Angina.

The heart is a pump made of muscles. Just like our arm muscles, it contracts and pumps blood out of the heart with pressure. The heart generates a pressure of around 120 mmHg, which is our blood pressure. Heart performs this work for approximately lac times a day. It does not take even one minute of rest. With this background, now let us feel two types of pain.

Just imagine you are doing this much work with your fist. You are squeezing a ball 72 times a minute and you have done this for 15 minutes. Your forearm will have pain. How you will describe this pain? What adjectives you will use for this? You will probably tell that your arm is tight, heavy and if you continue faster, this tightness will worsen. On resting, your forearm will be relaxed and tightness will go. What happened in the forearm at the time of pain? Oxygen deficit. Your arm needs oxygen as a supply and blood provide these oxygen supply. Your squeezing is the work, demanding oxygen. If the demand is more then supply it causes oxygen deficit. This is perceived as pain.
Imagine you are having cut over the forearm, stitches, swelling over the forearm. What type of pain you will describe? Sharp, shooting like, localised. You will not allow the doctor to move the forearm. On movement it causes pain. Here, pain occurs due to physical damage to muscles.

Both pain are muscular. The first one is due to oxygen deficit and the second one due to physical damage to muscles.

When this first type of pain occurs in the chest- it is most likely Angina. When the second type of pain occurs in the chest – it is most likely non-cardiac.

Which type of Angina I have?

Chronic stable angina

Angina occurring in a stable patient, with a fixed coronary block with no evidence of heart attack is called chronic stable angina. The patient has fixed supply-demand mismatch. Whenever his oxygen demand in heart muscles crosses fixed coronary oxygen supply due to fixed tight blockages, he will experience angina. On slowing down, the pain will be relieved.

This is not a heart attack.

This do have very good prognosis and can be managed with medicines very well.

Stable angina affecting the quality of life needs aggressive treatment including Angioplasty or Bypass surgery.

Unstable Angina

Angina occurring at rest, increasing severity of angina, angina occurring immediately after angioplasty or after bypass surgery is unstable angina.

This is a form of a heart attack. This is an emergency and if not treated on time, can be fatal.

Microvascular Angina, Syndrome X

Angina with abnormal Treadmill test but with normal Coronary angiography is due to microvascular blockages at the cellular level. This is called microvascular angina.

Vasospastic angina

This is another form of angina with normal coronary angiography and in this case, Coronary arteries do not have blockages. Coronary arteries here go into spasm in relation to exposure to specific stimuli like, cold. Its like a touch me not plant. Coronary artery gets relaxed after few minutes and pain is relieved.

This type of angina do have good prognosis and can be managed with medicines.

Refractory Angina

Angina not getting relieved with maximum tolerable medical management is called refractory angina.

What investigations I will need for my chest pain workup?

The cardiologist will take your detailed history and will be able to find out chances of having angina vs non-cardiac chest pain.

Any angina warrants attention as it signifies significant blockage in one of the major coronary arteries.

We document angina with the help of Treadmill test. If a patient is not able to do exercise on a treadmill then other options are nuclear stress test or Stress echocardiography, also called dobutamine stress echocardiography. Some patients have abnormal ECG from the beginning and we can’t do Treadmill test. These patients also go for nuclear imaging or stress echocardiography.

Echocardiography in patient with angina is most likely to be normal.

High-risk patients with multiple coronary risk factors with typical angina will be directly subjected to Coronary angiography.

Medical management of Stable Angina, what I should know.

Nitrates

Do I need to keep any pill in the pocket for an emergency?

For Chronic stable angina patient, I will recommend having Sorbitrate with them. Sorbitrate, when used properly in consultation with your cardiologist, can help you to go further. If the number of tablets needed per month is increasing, its time to get coronary angiography and get the blocks fixed.

How to use Nitrates?

Nitrates are drugs causing dilatation of blood vessels. Patients with Chronic stable angina do respond to this drugs with symptom relief. Sorbitrate tablet is given sublingually. Patient chews the tablet and keeps the crushed part below the tongue. This causes faster action of the drug. This do not remove the blockages. The effect lasts for few minutes. Patient can repeat the tablet after few hours if required. If patient is feeeling dizziness or pain is not relieved with two dose of sorbitrate he should reach to emergency in cardiology hospital.

It is important to store nitrate tablets properly to avoid moisture exposure and light exposure to preserve the drug effect.

Side effects of Nitrates

low blood pressure, headache, dizziness, flushing and increased heart rate.

Drug interaction

Do not combine nitrates with Sildenafil, Viagra or Cialis drugs taken for erectile dysfunction.

Control of Blood pressure.

Chronic stable angina patient does benefit immensely with the good control of blood pressure. Higher the blood pressure, higher the oxygen demand, earlier angina.

Other medicines for angina

After exhausting with nitrates and beta-blockers, we use CCB, Ranolazine and Nicorandil for the medical management of angina.

Nicoradil can cause mild headache.

EECP

Its non-invasive treatment option for refractory angina in a patient who is not a candidate for angioplasty or bypass surgery. These are very few patients who have a bad subset of blockages which can not be fixed by angioplasty or bypass surgery.

Remember, this is not an alternative to bypass surgery or angioplasty. If the patient is having refractory angina not responding to medicines he should undergo Coronary angioplasty or bypass surgery.

If the surgeon and cardiologist refuse for the invasive procedure due to the risk involved or due to poor target vessels, then only the patient should consider EECP.

How to choose between Angioplasty vs CABG/bypass surgery for severe angina? read here.