Angina (angina pectoris)

DEFINITIONS

Angina (angina pectoris) is chest pain or a temporary depression, which occurs when the heart muscle of oxygen deficiency.

Oxygen the heart needs to be determined by the weight of heart work (speed and power of heart rate).
Physical and emotional activity causes the heart work harder and therefore lead to increased cardiac oxygen demand.

If the narrowed or blocked arteries so that blood flow to the muscle can not be a heart needs oxygen, it can happen ischemia and cause pain.

CAUSE

Usually, angina is the result of coronary artery disease.
Other causes are:
- Aortic valve stenosis (narrowing of the aortic valve)
- Aortic valve regurgitation (leakage of the aortic valve)
- Subaortik stenosis hypertrophic
- Arterial spasm (contraction while in the arteries that occurs suddenly)
- Severe anemia.

SYMPTOMS

Not all patients experience angina ischemia. Ischaemia is not accompanied by angina is called silent ischemia.
Still not understood why some did not cause ischemia angina.

Usually angina sufferers feel as depression or pain below the breastbone (sternum).
Pain can also be felt in:
- On the left shoulder or left arm next to the
- Back
- Throat, jaw or teeth
- Right arm (sometimes).
Many patients describe the feeling as discomfort rather than pain.

Characteristic is that angina:
- Triggered by physical activity
- Lasted no more than a few minutes
- Will disappear if the patient relax.
Sometimes the patient will not predict the occurrence of angina after performing certain activities.

Angina is often worse if:
- Physical activity performed after dinner
- Cold weather
- Emotional stress.

Variant Angina
Is the result of coronary artery spasm at large on the surface of the heart.
Called variant as indicated by:
- Pain that arises when the patient is resting, not when doing physical activity
- Certain changes in the ECG.

Unstable Angina
Angina is a symptom pattern changes.
Characteristic of angina in a patient usually remains, therefore any change is a serious problem (msialnya pain becomes more severe, the attacks became more frequent, or pain occur when you're resting).
These changes were shown a rapid development of coronary artery disease, which has occurred because of blockage of a coronary artery atheroma or the outbreak of a bekuan.Resiko formation of a heart attack is very high.
Unstable angina is an emergency.

Diagnosis

The diagnosis is established primarily based on the symptoms.
Among even during serangn angina, physical examination or EKG showed only minimal abnormalities.

During an attack, heart rate can be slightly increased, blood pressure increases and could hear the distinctive changes in heart rate through a stethoscope.
During an attack, can be found on the ECG changes, but between attacks, the ECG may show normal results, even in people with coronary artery disease is severe.

If the typical symptoms, the diagnosis is easily established.
Type of pain, the location and relationship with activities, food, weather and other factors will facilitate the diagnosis.

Particular examination can help determine the weight of ischemia and coronary artery disease:

1. Exercise tolerance testing is an examination where the patient walk on a treadmill and monitored with an EKG.
This examination can assess the weight of coronary artery disease and heart's ability to respond to ischemia.
These tests also can help determine whether or not done or arteriografi coronary surgery.
2. Radionuclide imaging is performed in conjunction with exercise tolerance testing can provide valuable information about angina.
Depictions of radionuclides not only strengthen the ischemia, but also determine the areas and extent of the affected heart muscle and shows the amount of blood to the heart muscle.
3. Exercise echocardiography is an investigation where an echocardiogram obtained by ultrasonic waves reflected from the heart.
This examination may show heart size, heart muscle movement, blood flow through heart valves and valve function.
Echocardiogram performed at rest and at peak activity.
If there is ischemia, the pumping motion of the left ventricle wall appeared abnormal.
4. Coronary Arteriografi can be done if the diagnosis of coronary artery disease or ischemia is uncertain.
This examination is used to determine the weight of coronary artery disease and to help determine whether or not to do coronary artery bypass surgery or angioplasty.
5. Continuous ECG monitoring with Holter monitors showed abnormalities of silent ischemia.
6. Angiography can sometimes find a coronary artery spasm that does not have an atheroma.

TREATMENT

Treatment begins with efforts to prevent coronary artery disease, slowing or fight with progresivitasnya overcome risk factors.
The main risk factors (eg increased blood pressure and cholesterol levels), treated as they should.
The most important risk factors that could prevent the smoking of cigarettes.

Angina treatment mainly depends on the weight and stability of the symptoms.
If symptoms are stable and mild to moderate, the most effective is to reduce risk factors and take your medicine.

If symptoms worsen quickly, usually treated immediately and patients are given medication at the hospital.
If symptoms do not disappear with medication, dietary changes and lifestyle, it can be used angiography to determine whether or not to do coronary artery bypass surgery or angioplasty.

STABLE angina

Treatment intended to prevent or reduce ischemia and minimize symptoms.
There are 4 kinds of drugs given to patients:

1. Beta-blockers
These drugs affect the effect of hormones epinephrine and norepinephrine on the heart and other organs.
Beta blockers reduce the heart rate at rest. During the activity, beta-blockers limit the increase in heart rate, thereby reducing the need for oxygen.
Beta-blockers and nitrates has been shown to reduce the incidence of heart attacks and sudden death.

2. Nitrates (eg nitroglycerin).
Nitrate causes dilation of blood vessel walls, there is in the form of short-acting and long-acting.
A nitroglycerin tablet placed under the tongue (sublingual) usually will eliminate symptoms of angina within 1-3 minutes, and the effect lasted for 30 minutes.
Patients with chronic stable angina should always carry nitroglycerin tablets or spray at any time.
Swallow a tablet just before doing activities that the patient is known to trigger the occurrence of angina, it helps patients.
Nitroglycerin tablets may also sandwiched between the gums and inner cheek or the patient can inhale nitroglycerin sprayed into the mouth, but that is widely used is the use of sublingual nitroglycerin tablets.

Long-acting nitrates taken as much as 1-4 times / day.
Nitrate is also present in the form of adhesive tape and skin, where the drug is absorbed through the skin for several hours.
Long-acting nitrates are consumed on a regular basis can quickly lose its ability to reduce symptoms. Therefore, most experts recommend an interval of 8-12 hours free during the drug to maintain long-term effectiveness.

3. Calcium antagonist
This drug prevents blood vessels and pengkerutan can overcome coronary artery spasm.
Calcium antagonists are also effective in treating variant angina.
Some calcium antagonists (eg verapamil and diltiazem) can slow the heart rate.
These drugs can also be combined with beta-blockers to prevent the occurrence of episodes of tachycardia (heart rate very quickly).

4. Antiplatelet (eg aspirin)
Platelets is a necessary factor for the occurrence of blood clots when bleeding occurs. But if the platelets collected on atheroma in the arterial wall, the formation of these clots (thrombosis) can be narrowed or clogged arteries, causing heart attacks.
Aspirin bound to platelets and prevent clots forming in the blood vessel walls, so aspirin reduces the risk of death from coronary artery disease.
Patients who are allergic to aspirin, could use triklopidin.

Stable Angina

Unstable angina

In general, people with unstable angina should be treated, so that drug delivery can be closely monitored and other therapies can be provided if necessary.

Patients get the drug to reduce the tendency of blood clots, namely:
- Heparin (an anticoagulant that reduces the formation of blood clots)
- Inhibiting the glycoprotein IIb / IIIA (eg absiksimab or tirofiban)
- Aspirin.

Also given beta-blockers and intravenous nitroglycerin to reduce the heart's workload.
If the administration of drugs is not effective, may have to be done and arteriografi coronary angioplasty or bypass surgery.

Coronary artery bypass surgery

This highly effective surgery performed on people with angina and coronary artery disease is not widespread.
This surgery can improve patient tolerance of activity, reduce symptoms and decrease the amount or dose of medication required.

Surgery performed severe angina in patients who:
- Does not show improvement in the provision of medicines
- Previously not had a heart attack
- Normal heart function
- Do not have other conditions that endanger the surgery (such as chronic obstructive pulmonary disease).

This surgery is a vein or artery graft from the aorta to the coronary arteries, which had to skip the blockage.
Artery is usually taken from the lower sternum. The artery becomes blocked, and rarely more than 90% are still functioning well within 10 years after surgery.
Vein transplant would gradually becomes blocked.

Coronary angioplasty

The reason for the same reason angioplasty for bypass surgery.
Not every blockage can undergo angioplasty, this depends on the location, length, weight Calcification or other circumstances.

Angioplasty begins with a piercing large peripheral artery (usually the femoral artery in the thigh) with a large needle. Then put a long guide wire through the needle into the arterial system, through the aorta and into the clogged coronary artery.
A catheter (small tube) is inserted at the end of the balloon is inserted through the guide wire to the blockage. The balloon then developed for a few seconds, then deflated.
Developing and balloon deflation is repeated several times.

The patient watched closely because as long as the balloon inflates, there could be a blockage of blood alliran moment. This blockage will change and lead EKG ischemia symptoms.

The balloon is expanded to suppress atheroma, resulting in stretching the artery and perobekan layer in the formation of arterial blockages in place.
If successful, angioplasty can open as many as 80-90% blockage.

Approximately 1-2% of patients died during the angioplasty procedure and 3-5% had a heart attack is not fatal.
Within 6 months (often within the first few weeks after the angioplasty procedure), coronary artery becomes blocked again in about 20-30% sufferer.

Angioplasty often must be repeated and can control coronary artery disease in a long time.
In order to keep arteries open, use the latest procedures, where a device made of a coil of wire (stent) is inserted into the artery. In 50% of patients, this procedure seems to reduce the risk of subsequent arterial blockage.

Prognosis

Key factor in predicting what will happen to people with angina are age, extent of coronary artery disease, weight and the most important symptom is the amount of heart muscle that is still functioning normally.
The more broadly the affected coronary artery or the blockage worse, then getting a bad prognosis.

A good prognosis was found in people with stable angina and patients with normal pumping ability (ventrikelnya normal muscle function). Reduced pumping capacity would aggravate the prognosis.

PREVENTION

The best way to prevent the occurrence of angina is to modify risk factors:
- Stop smoking
- Losing weight
- Controlling blood pressure, diabetes and cholesterol.