Disease angina
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Understanding Angina: Diagnosis, Management, and Prognosis
Introduction to Angina and Its Prevalence
Ischaemic Heart Disease (IHD) and Angina
Ischaemic heart disease (IHD) remains the leading global cause of death, with angina pectoris being a common clinical manifestation. Angina, characterized by chest discomfort due to myocardial ischaemia, affects approximately 3-4% of adults in the UK, leading to significant healthcare resource utilization.
Diagnosis and Classification of Angina
Diagnostic Criteria and Historical Context
Angina is typically diagnosed based on the presence of chest pain that occurs with exertion or stress and is relieved by rest or nitroglycerin. The condition was first described in the 18th century, with subsequent studies linking it to coronary artery disease (CAD). The NICE guidelines define typical angina as requiring all three of the following: substernal chest pain, onset with exertion or stress, and relief with rest or nitroglycerin.
Unstable Angina Classification
Unstable angina, a critical phase of coronary heart disease, has been classified based on clinical symptoms and prognosis. This classification aids in treatment decisions and patient management. Recent advancements have identified markers such as cardiac-specific troponins, which help predict early risk and guide therapy .
Angina Without Obstructive Coronary Artery Disease (ANOCA)
Prevalence and Challenges
A significant subset of patients with angina do not have obstructive CAD, a condition known as ANOCA. This group poses diagnostic and therapeutic challenges due to the heterogeneous nature of the underlying vascular disorders .
Coronary Microvascular Disease (CMD)
Approximately two-thirds of ANOCA patients have CMD, characterized by impaired coronary flow reserve (CFR) and vasomotor dysfunction. CMD can be secondary to structural changes in the microcirculation or vasomotor dysfunction, leading to myocardial ischaemia and adverse cardiovascular outcomes.
Stratified Medical Therapy and Invasive Testing
CorMicA Trial Findings
The CorMicA trial demonstrated that stratified medical therapy, guided by invasive coronary function testing, significantly improves health status in ANOCA patients. This approach includes assessing coronary flow reserve, microcirculatory resistance, and vasoreactivity, leading to better angina management and quality of life.
Invasive Evaluation Techniques
Invasive evaluation, including endothelial function assessment and intravascular ultrasound, reveals that most ANOCA patients have occult coronary abnormalities. This comprehensive assessment provides critical diagnostic information, influencing treatment and outcomes.
Long-term Prognosis and Quality of Life
Prognostic Factors
The long-term prognosis of ANOCA patients varies, with factors such as dyslipidaemia, diabetes, and hypertension influencing outcomes. Studies show that patients with some degree of coronary atherosclerosis or documented myocardial ischaemia have worse clinical outcomes.
Impact on Quality of Life
Angina significantly impacts patients' quality of life, leading to recurrent hospitalizations and persistent symptoms. Tools like the Seattle Angina Questionnaire help measure the functional status and quality of life in these patients, guiding treatment decisions.
Conclusion
Angina, particularly in the absence of obstructive CAD, presents a complex clinical challenge. Advances in diagnostic techniques and stratified medical therapy have improved patient outcomes and quality of life. Ongoing research and tailored treatment approaches are essential for managing this prevalent and impactful condition.
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