Angina pectoris

Angina pectoris is defined as
an inadequate supply of
oxygen to the heart muscle
which is typically severe and
crushing and is
characterized by feeling of
pressure and suffocation
just behind the breast bone.

 High cholesterol level
 High blood pressure
 Smoking
 Uncontrolled diabetes mellitus
 Obesity
 Metabolic syndrome
 Lack of physical activity
 Age
 Cold climate

Hyperhomocysteinemia
Strong emotions
Consumption of heavy meals
Sexual activity
Stimulants
Coronary artery disease

Due to etiological and risk factors
Blockage of coronary artery
Imbalance between myocardial oxygen demand
and supply
Myocardial ischemia
Deprived glucose in myocardial cell for aerobic
metabolism
Production of lactic acid and its accumulation
Lactic acid irritates myocardial nerve fiber
Transmits pain message to cardiac nerve and
upper thoracic posterior root
Angina pectoris

Substernal/ precordial pain
ONSET: quickly/slowly
LOCATION: retrosternal/ slightly left to
sternal
RADIATION: Left shoulder , upper arm
and may travel down the inner aspect of
left arm to the elbow wrist and 4th or 5th
finger. May radiate to right shoulder, neck,
jaw or epigastric region.
DURATION: Last less than 5 minutes.
Attacks precipitated by heavy meal /
extreme anger may last 15-20 minutes.

SENSATION: squeezing, burning pressing,
choking, aching or bursting pressure.
SEVERITY: mild to moderately severe

Dyspnea
Pallor
Sweating
Fainting
Palpitation
Dizziness
Digestive disturbance

 STABLE ANGINA:
Chest pain occurs intermittently
Over a long period
Triggered by: exertion, emotion
Same pattern of onset, duration and intensity of
symptoms
 UNSTABLE ANGINA
Paroxysmal chest pain
Occurs even on rest/ sleep
Attacks characteristically increases in number, duration
and severity
Triggered by: unpredictable degree of exertion, emotion.
Requires immediate hospitalisation

 PRINZMETAL ANGINA:
Occurs at rest as a response to spasm of major
coronary artery
Rare form
Can occur during rapid eye movement sleep when
myocardial oxygen consumption increases.
It may relieve by rest

 ANGINA DECUBITUS
Occurs when person is lying down
Occurs because gravity redistributes fluids in body
which makes heart work harder
Relieved by sitting or standing
 NOCTURNAL ANGINA
Occurs at night
 INTRACTABLE ANGINA: chronic incapacitating
angina that does not response to interventions
 POST INFARCTION ANGINA: pain occurs after MI
when residual ischemia may cause episodes of
angina

Health history
Physical examination

 Cardiac enzyme
ENZYME NORMAL VALUE
CK-MB 5 to 25 IU/L Rise in 3-12 hours
Peaks 24 hours
Normalizes in 48-72
hours
MYOGLOBIN Doubles in value
within 2 hours of MI
0 to 85 ng/mL
Rise in 1-4 hours
Peaks 6-7 hours
Normalizes in 24
hours
Troponin T Greater than 2ng/
ml
Rise in 3-12 hours
Peaks 12-48 hours
Normalizes in 14
days
Troponin I >0.03mcg/l Rise in 3-12 hours
Peaks 24 hours
Normalizes in 5-10
days

4/20/2020 16MYOCARDIAL INFARCTION
STEMI

ECG STRESS TEST
4/20/2020MYOCARDIAL INFARCTION 17

DIAGNOSTIC
EVALUATIONS CONT.
 ISOTOPE SCANNING
4/20/2020 19

 CORONARYANGIOGRAPHY
4/20/2020MYOCARDIAL INFARCTION 20

Presentation with chest pain
Assess nature, characteristics, location and
quality
Angina unlikely angina likely
Avoid unnecessary test primary
secondary
Manage risk able to exercise investigate
normal resting ECG
treat

Yes no
Exercise ECG Myocardial perfusion
imagining
High risk low risk
Angiography medical treatment

Establish and maintain airway
Anticipate need for intubation
Administer oxygen
Start 2 IV lines
Loosen clothes
Monitor cardiac rate and rhythm

Monitor vital signs
Take 12 lead ECG
Be prepared to perform CPR
Assess severity and location of pain
Obtain past heath history
Assess indication and contraindication of
thrombolytic therapy

 Acute pain related to oxygen supply and demand imbalance
as evidenced by pain score
 Decreased cardiac output related to decrease cardiac
contractility and dysrhythmias as evidenced by ECG
monitoring
 Activity intolerance related to cardiac dysfunction, changes
in oxygen supply and consumption as evidenced by
shortness of breath
 Anxiety related to chest pain, fear of death as evidenced by
facial expression

 A pilot project was done to examine the clinical
effects of long-term low-dose androgens in men with
angina. Forty-six men with stable angina completed
a 2-week, single-blind placebo run-in, followed by
double-blind randomization to 5 mg testosterone
daily by transdermal patch or matching placebo for
12 weeks, in addition to their current medication.
 Time to 1-mm ST-segment depression on treadmill
exercise testing and hormone levels were measured
and quality of life was assessed by SF-36 at baseline
and after 4 and 12 weeks of treatment.

 Active treatment resulted in a 2-fold increase in
androgen levels and an increase in time to 1-mm ST-
segment depression from 309±27 seconds at baseline to
343±26 seconds after 4 weeks and to 361±22 seconds
after 12 weeks.
 This change was statistically significant compared with
that seen in the placebo group; P=0.02 .
 The magnitude of the response was greater in those with
lower baseline levels of bioavailable testosterone
(r=−0.455, P<0.05).
 There were significant improvements in pain perception
(P=0.026) and role limitation resulting from physical
problems (P=0.024) in the testosterone-treated group.
 Low-dose supplemental testosterone treatment in men
with chronic stable angina reduces exercise-induced
myocardial ischemia.

Angina pectoris

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