Angina pectoris, also known as typical angina or stabilized angina, is a sign of myocardial ischemia. It is partial chest pain provoked by effort and relieved by rest or nitrogylcerin. It is the first complaint or sign of underlying coronary artery disease. In the United States, angina affects ten million people. It is not only important to recognize signs and symptoms, but management of the condition considerably manages the individuals. 

Coronary disease affects more than 17 million adults in the US. Among the 17 million Americans influenced, 55 percent are men. Every year, this leads to more than 500,000 deaths in the United States. At 40 years old, men have a 49% likelihood of developing heart disease in their lifetime whereas women have 32%. Although occurrences of coronary events rise as individuals get older; there is a gradual decrease of males with these incidents due to their advanced age. 

The countries that have the highest rates of death from ischemic heart diseases are low, middle, and high income countries which means that they are not unique to the U.S. adults. 

Angina is due to a lack of balance in the supply and demand factors for myocardial oxygen. Vascular tone regulation and anti-thrombotic activity of coronary artery endothelial cells may be disrupted by stress, hypertension hypercholesterolemia, viruses, bacteria or immune complexes. The commonest cause of myocardial ischemia is stenosis of the coronary arteries which prevents sufficient oxygen delivery during periods when requirements are high. Myocardial supply depends on many things including size and tone of the coronary vessels, collateral blood flow pressure difference between aortic diastolic and ventricular endocardial perfusion per minute heart rate.  Mechanoreceptive and chemo sensitive receptors may get stimulated in the fibers of cardiac muscle when the myocardial demand for oxygen increases than supply. Understanding the exact cause of angina is important for medical treatment and management of risks. 

The mechanism behind stable angina is the result of supply-demand mismatch. The myocardial oxygen demand transiently exceeds the myocardial supply of oxygen, which often leads to the manifestation of symptoms. There are various factors that contribute to stable angina, and the most common one is coronary artery stenosis. 

The probability of diagnosis varies with the type of stable angina that a person has. This makes it an absolute necessary to control risk factors in all cases. It is important to always look for an increase in frequency of symptoms or development to an unstable angina. 

Stable angina often presents as subacute, requiring a thorough medical history and physical examination to identify high-risk individuals. Regular screening measures include blood pressure, sleep patterns, weight, stress levels, exercise tolerance, and substance use. Typical symptoms include chest discomfort or anginal equivalents, and distinguishing between cardiac and non-cardiac chest discomfort is crucial.  

Occasionally, patients may have stable angina or equivalent symptoms and yet have entirely normal findings on physical examination. However, in the presence of a compatible clinical syndrome, angina pectoris can be diagnosed with reasonable reliability if the Levine sign is positive. Third or fourth heart sound may be heard during anginal attack which is caused due to LV dysfunction and mitral regurgitation may occur due to dysfunction of papillary muscle. 

Common angina is felt as feeling of pressure, squeezing or pain in the chest. Instead of a specific place, a broad area of the chest is generally affected, and the pain can move depending on which dermatomes are being touched. Symptoms are known to increase when there is a lot of demand like walking for long distances or carrying heavy loads up stairs along with emotional stress. 

Usually, symptoms last for about less than five minutes and are relieved by stopping an activity that causes them or else taking nitroglycerin. There will not be any noticeable findings during physical examinations.   

Typical angina can be manifested by heaviness, tightness, pressure-like, or squeezing. It is crucial to identify the differences between non-cardiac and cardiac chest discomfort. 

Acute coronary syndrome 

Stable angina consists of modifications of lifestyle such as cessation of smoking, intake of diet healthy for heart, exercise and management of weight. Medications like antiplatelet agents, beta-blockers, calcium channel blockers and nitrogylcerin would be prescribed for this condition. In cases where symptoms persist or high- risk features occur, invasive interventions like coronary artery revascularization may be considered. The treatment varies among patients based on lifestyle, pharmacological management etc. 

Cardiology, General

Cessation of smoking 

Smoking cigarettes is the primary contributor to premature moratlity. Cardiovascular mortality risk is higher in smokers than non-smokers. Hence, it is important to educate people to stop smoking irrespective of age. 

Obesity 

A healthy weight is necessary for a healthy heart. This is the second modifiable factor that contributes to mortality. Based on individual response, weight loss methods should be designed for each patient. 

Control of blood pressure 

The 2017 AHA/ACC guidelines establish hypertension as having a systolic blood pressure ≥130 mmHg or diastolic pressure ≥80 mmHg. While individualized goal blood pressure targets are essential, it is crucial to recognize that every 20/10 mmHg rise in systolic/diastolic blood pressure corresponds to a twofold increased risk of mortality related to coronary heart disease and stroke, as supported by evidence. 

Cardiology, General

Aspirin: It prevents the aggregation of platelets by irreversible inhibition of cyclooxygenase following suppression of thromboxane A2. Its antiplatelet activity lasts for 7 days. 

Clopidogrel: This drug selectively inhibits the binding of ADP to platelet receptors after activation of GPIIb/IIIa complex which further inhibits the aggregation of platelets. 

Cardiology, General

Metoprolol: It is a selective blocker of beta-1 adrenergic receptor and reduces the automaticity of contractions. Being lipophilic, it is capable of penetrating into CNS. 

Atenolol:  This blocks the β-1 adrenergic receptors selectively with no or little effect on β-2 receptor.  

Propranolol: It is a non-selective beta-blocker which is lipophilic. 

Amlodipine: It inhibits the entry of calcium ions into slow channels and voltage-sensitive parts of myocardium and vascular smooth muscle during depolarization. 

Diltiazem: It inhibits the entry of calcium ions into slow channels and voltage-sensitive parts of myocardium and vascular smooth muscle during depolarization. 

Verapamil: It inhibits the entry of calcium ions into slow channels and voltage-sensitive parts of myocardium and vascular smooth muscle during depolarization. 

Cardiology, General

Nitroglycerin IV: This drug leads to the relaxation of smooth muscles by stimulating the production of intracellular cyclic GMP. 

Cardiology, General

Isosorbide: It causes relaxation of vascular smooth muscles via stimulation of intracellular cGMP. It also decreases the preload (LV pressure) and after load (arterial resistance). 

Cardiology, General

Ramipril: This medication prevents the conversion of angiotensin I to a potent vasoconstrictor, angiotensin II that results in the reduced secretion of aldosterone. 

Cardiology, General

Ranolazine: It is a cardioselective anti-ischemic agent which inhibits the oxidation of fatty acids partially. It also prolongs the QT interval by inhibiting late sodium current into the myocardial cells. It is employed in treating chronic angina that is not responsive to other antianginal drugs. 

Cardiology, General

Coronary artery disease is the cause of most deaths in the United States. Teaching people about the signs and symptoms of heart attack, unstable angina, and stable angina is important. People must be educated about the preventive measures like modification of risk factor and following healthy lifestyle.