Angina pectoris
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Understanding Angina Pectoris: Classification, Risks, and Treatment
Definition and Classification of Angina Pectoris
Angina pectoris is a clinical syndrome characterized by chest pain due to myocardial ischemia, typically triggered by physical or emotional stress. The pain is often described as retrosternal and may radiate to the left arm. The Canadian Cardiovascular Society (CCS) classifies angina into four classes based on symptom severity, ranging from class I (angina with strenuous activity) to class IV (angina at rest) .
Stable Angina Pectoris and Non-Obstructive Coronary Artery Disease
Stable angina pectoris occurs predictably with exertion and is relieved by rest or nitroglycerin. Interestingly, patients with stable angina but no obstructive coronary artery disease (CAD) are still at increased risk for major adverse cardiovascular events (MACE) and all-cause mortality. Studies have shown that even with normal coronary arteries or diffuse non-obstructive CAD, these patients have significantly higher risks of cardiovascular death, myocardial infarction, stroke, and heart failure compared to a reference population without ischemic heart disease.
Variant Angina Pectoris
Variant angina pectoris, also known as Prinzmetal's angina, is characterized by anginal pain at rest, often occurring at night or early morning, and is associated with transient ST-segment elevation on an electrocardiogram. This type of angina is typically due to coronary artery spasm rather than atherosclerosis. Patients may experience severe arrhythmias, including ventricular tachycardia and fibrillation, necessitating interventions such as pacemaker insertion.
Unstable Angina Pectoris
Unstable angina pectoris is a more severe form of angina that occurs unpredictably and may not be relieved by rest or medication. It is often a precursor to myocardial infarction. Studies comparing medical and surgical treatments for unstable angina have shown that while surgical treatment may provide better pain relief, the long-term survival rates are not significantly different between the two approaches. However, patients with significant left main coronary artery disease have a high operative and postoperative mortality rate .
Pathophysiology and Central Nervous Pathways
The pathogenesis of angina pectoris involves myocardial anoxemia, where the heart muscle receives insufficient oxygen. The central nervous pathways mediating angina involve increased regional cerebral blood flow in areas such as the hypothalamus, thalamus, and prefrontal cortex during anginal episodes. These brain regions are thought to be responsible for the perception of anginal pain, with the thalamus acting as a gate for pain signals.
Treatment Options
Treatment for angina pectoris includes lifestyle modifications, pharmacotherapy, and revascularization procedures. Anti-anginal drugs such as nitrates, calcium antagonists, and beta-blockers are first-line treatments. For patients with persistent symptoms or significant ischemic burden, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) may be indicated. While PCI can improve symptoms, it does not necessarily improve long-term outcomes in stable coronary artery disease.
Conclusion
Angina pectoris is a complex syndrome with various forms and underlying mechanisms. Understanding its classification, associated risks, and treatment options is crucial for effective management. Despite advancements in medical and surgical therapies, ongoing research is needed to address the limitations and improve patient outcomes.
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