ANGINA PECTORIS

•‘Angina pectoris’ is a Latin phrase that means "strangling in

the chest." Unlike a heart attack, the heart muscle is not
damaged forever, and the pain usually goes away with rest.

DEFINITION
Heart disease characterized by chest pain that occurs as a result
of inadequate oxygen and blood supply to the myocardium.

Angina is characterized by a sudden, severe pressing substernal

pain radiating to the left arm.
TYPES

1. Stable Angina
2. Unstable Angina
3. Myocardial Infarction

1. Stable Angina
Predictable pattern of exertional pressure sensation in the
anterior chest relieved by rest or nitroglycerin.

History: Chest pain described as tightness, pressure or aching that

is typically located in the substernal area, radiating down one or
both arms for 5 minutes or less, precipitated by exercise or
emotional stress and relieved by rest or nitroglycerin.
2. Unstable Angina

This is characyerized by pain that occurs at rest.

History: More severe anginal pain that lasts more than
30 minutes or that occurs during rest and is not relieved
by rest or sublingual nitroglycerin.

3. Myocardial Infarction

This type of angina refer to "Emergencies of the

Cardiovascular System.
It is the interruption of blood supply to the heart due to
block of coronary artery by thrombus, resulting in
ischemic injury and necrosis of a portion of the
myocardium.
 CAUSES OF ANGINA

Angina pectoris is the result of myocardial ischemia,

which occurs when the cardiac workload and
myocardial oxygen demands exceed the ability of
the coronary arteries to supply oxygenated blood.

It is the main clinical expression of coronary artery

disease (subintimal deposition of atheromas in the
large and medium-sized arteries serving the heart)
(atherosclerosis of coronary arteries).
 Risk Factors

• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Cigarette smoking
• Family history of premature coronary artery disease
(e.g., father died of coronary artery disease before
reaching 60 years of age).
• Use of oral contraceptives.
• Sedentary lifestyle.
• Obesity
 MANAGEMENT OF ANGINA

Nonpharmacologic Interventions
• To change lifestyle (e.g. dietary modifications to reduce fat and
cholesterol).
• To reduce weight, stop smoking, avoid strenuous exercise but
increase moderate exercise (e.g., walking).
Pharmacologic Interventions
Nitroglycerin: It works by widening (dilating) the blood vessels,
which improves blood flow and allows more oxygen-rich blood
to reach the heart muscle. It works in seconds.

 blockers & Ca2+ channel blockers: reduce the O2 needs of the

heart by slowing the heart rate or lowering blood pressure. They
also reduce the irregular heartbeat, called an arrhythmia.
 Angina
Angina pectoris is a Latin phrase that means "strangling in the chest." Patients often say that angina is like a squeezing, suffocating, or
burning feeling in their chest, but an episode of angina is not a heart attack. Unlike a heart attack, the heart muscle is no t damaged
forever, and the pain usually goes away with rest.
What causes angina?
Angina is the pain you feel when a diseased vessel in your heart (called a coronary artery) can no longer deliver enough blood to a part
of your heart to meet its need for oxygen. The heart's lack of oxygen-rich blood is called ischemia. Angina usually happens when your
heart has an extra need for oxygen-rich blood, like during exercise. Other triggers can be emotional stress, extreme cold or hot
temperatures, heavy meals, alcohol, and smoking.
Angina attacks in men usually happen after the age of 30 and are nearly always caused by coronary artery disease (CAD). For women,
angina tends to happen later in life and can be caused by many different factors. Causes other than CAD include narrowing of the
aortic valve in the heart (aortic stenosis), a low number of red blood cells in the bloodstream (anemia), or an overactive thyroid
(hyperthyroidism).
What are the symptoms?
Angina is usually a symptom of CAD. People with angina have a greater chance of having a heart attack than those who do not have
symptoms of CAD.
Angina tends to start in the center of the chest, but the pain may spread to your left arm, neck, back, throat, or jaw. You may have
numbness or a loss of feeling in your arms, shoulders, or wrists. An episode usually lasts no more than a few minutes. But if the pain
lasts longer than a few minutes, it may mean that you have a sudden total blockage of a coronary artery or that you may be having a
heart attack.
Patients may have one of several types of angina. Those with stable angina usually know the level of activity or stress that brings on
an attack. Patients should also keep track of how long their attacks last, if the attacks feel different from other attacks they have had,
and whether medicine helps ease the symptoms. Sometimes the pattern changes—attacks happen more often, last longer, or happen
without exercise. A change in the pattern of attacks may mean that patients have what is called unstable angina, and they should see a
doctor as soon as they can. Patients who have new, worsening, or constant chest pain have a greater risk of heart attack, an irregular
heartbeat (arrhythmia), and even sudden death.
Other Types of Angina
Variant angina pectoris, or Prinzmetal's angina, is a rare form of angina caused by something called coronary spasm (vasospasm).
The spasm temporarily narrows the coronary artery, so the heart does not get enough blood. It may happen in patients who also have a
severe buildup of fatty plaque (atherosclerosis) in at least one major vessel. Unlike typical angina, variant angina usually happens
during times of rest. These attacks, which may be very painful, tend to happen regularly at certain times of the day.
Microvascular angina is a type of angina where patients have chest pain but do not seem to have a blockage in a coronary artery. The
pain in the chest is because the tiny blood vessels that feed the heart, arms, and legs are not working properly. Generally, patients cope
well with this type of angina and have very few long-term side effects.
 Antianginal drugs

1. Organic nitrates
• Nitroglycerine
• Isosorbide dinitrate
2.  Blockers
• Propanolol
3. Ca2+ channel blockers
• Diltiazem
• Nifedipine
• Verapamil
Organic nitrates- Mechanism of action
Nitrates

 Nitric oxide (NO) (nitrate is converted to NO)

Activation of guanylyl cyclase by NO

 cGMP

 Dephosphorylation of myosin light chain

Vascular smooth muscle relaxation

 Myocardium perfusion,  O2 demand & relieve pain

 Pharmacological effects of nitrates

A. Effects on peripheral vessels

• Dilatation of large vein, resulting in pooling of blood in the
veins.
• This diminishes preload (venous return to the heart) and 
work of heart.

B. On heart
• Dilates the coronary vessels and increases blood supply to the
heart muscle.
•  in myocardial oxygen consumption by decreased cardiac
work.
 Therapeutic use of nitrates:

• Angina pectoris (prophylaxis and treatment

• Congestive heart failure
• Myocardial infarction

Adeverse effect Pharmacokinetics

1. Headache •Onset of action: 1 min (nitroglycerine)

2. Hypotension 1 hr (isosorbide)
3. Facial flashing •Route of administer: sublingual or
4. Tachycardia transdermal patch
 -Adrenergic Blockers

 -Adrenergic blockers suppress the activation of the heart

by blocking  receptors.

• They reduce the work of the heart by decreasing CO.

  blockers reduce the frequency and severity of angina

attacks.

• These agents are particularly useful in the treatment of

patients with myocardial infarction.

 -Adrenergic blockers can be used with nitrates tolerance

• They are contraindicated in patients with diabetes or

obstructive pulmonery disease.
 Ca2+ channel blockers

• Ca2+ channel blockers inhibit the entrance of Ca2+ into

cardiac and smooth muscle cells of the coronary and
systemic arteries and cause a decrease in smooth
muscle tone and vascular resistance.

• So decrease after load and decrease work load of

heart.