What is angina pectoris?

 Angina pectoris ( effort angina or chronic stable angina ) is a pain that occurs in the chest and in the surrounding areas (arms, neck, back and even the jaw) due to a lack of oxygen which is about the heart.

What are the causes of angina pectoris?

L ‘ angina is a heart disease that begins with damage to the inner wall of coronarie.Si is a slow process that can begin even at a young age.
Coronary wall damage can be caused by several factors:

  • smoke
  • familiarity (genetic predisposition)
  • hypertension
  • dyslipidemia
  • diabetes mellitus
  • chest radiation therapy (used to treat some forms of cancer)

In the presence of these causes, the internal wall of the artery can be damaged, favoring the formation of plaques (deposits) composed of cholesterol and other cellular products that tend to accumulate in the place where arterial damage occurred.
This process is called atherosclerosis . If the plaques break, the blood cells (platelets) are activated in an attempt to repair the internal surface of the artery. This attempt, albeit ideally protective, can however lead to the triggering of events that can determine the complete occlusion of the vessel and therefore cause myocardial infarction .

What are the symptoms of angina pectoris?

When the coronary arteries become blocked, they cannot guarantee an adequate supply of blood and nutrients to the heart, especially in conditions in which it requires more, for example when it needs to contract more quickly and when it must generate a higher blood pressure, as happens during exercise or emotional stress.
In the presence of atherosclerotic plaques obstructing the coronary arteries, the typical symptoms of ischemic heart disease can therefore occur.

These include:

  • chest pain (angina) : pain or discomfort with tightness, burning or heaviness in the chest (“as if someone were sitting in the chest”). This annoyance, called angina, is generally triggered by physical or emotional stress. It generally disappears within a few minutes with the interruption of the stress source. In some, generally in women, it can be fleeting or punctiform and manifest itself in the abdominal, shoulders or back;
  • shortness of breath (dyspnoea) .

The formation of atherosclerotic plaques obstructing the coronary arteries is favored by a series of risk factors whose control is fundamental in primary prevention (avoiding the appearance of angina in those who do not have it) or secondary (avoiding recurrence in those who have already had it) .

The risk factors

Among the risk factors of angina pectoris (but more generally of atherosclerotic arteriopathy) are:

  • age: with increasing years the risk of coronary damage and obstruction increases;
  • gender: men generally have a higher risk of coronary heart disease. The risk for women increases after menopause;
  • familiarity: the risk becomes higher if the father or brother has suffered from coronary artery disease before the age of 55, or the mother or sister before the age of 65;
  • smoke: nicotine contributes to blocking the coronaries, carbon monoxide can damage the internal surface;
  • arterial hypertension: if not controlled it can cause the coronary wall to harden and thicken with consequent obstruction of the canal (lumen) through which the blood flows;
  • high cholesterol: high levels of cholesterol (in particular LDL, ie “bad” cholesterol) in the blood can increase the risk of plaque formation and therefore of atherosclerosis. Atherosclerosis can also be favored by low levels of “good” cholesterol ( HDL );
  • diabetes mellitus: diabetes and angina pectoris share common risk factors, such as obesity and hypertension;
  • obesity: obesity typically worsens other risk factors;
  • sedentary lifestyle: lack of exercise is associated with coronary heart disease and some of its risk factors;
  • intense  and uncontrollable stress : it can both damage the arteries and worsen the risk factors of coronary heart disease.

Risk factors often coexist and each can contribute to the onset of the other: obesity, for example, contributes to the onset of diabetes and hypertension. If you have multiple risk factors, you have a higher risk of coronary heart disease. The metabolic syndrome, a condition that includes high blood pressure, hypertriglyceridaemia, insulin resistance and excess weight (abdominal), predisposes, for example, to a greater risk of coronary heart disease.

The diagnosis

The tests required for the diagnosis of angina pectoris include:

  • Visit with electrocardiogram (ECG)
  • Echocardiogram
  • Provocative tests of ischemia
  • Stress test
  • Eco-stress
  • Perfusional myocardial scintigraphy
  • Stress heart resonance (MRI stress)
  • Cardiac CT
  • Magnetic resonance imaging (MRI) of the heart
  • Coronary angiography (coronary arteriography)

The treatment of angina pectoris involves changing the lifestyle and taking certain types of drugs.

The treatment

Lifestyle changes

  1. Abstention from smoking Regular and aerobic exercise helps to achieve and maintain adequate weight by avoiding an increase in cholesterol and blood pressure. The goal is to perform 30 to 60 minutes of physical activity more or less every day of the week.
  2. Reduction in intake of foods containing saturated fatty acids (e.g. cheeses and sausages etc.), cholesterol and sodium, can help control weight, blood pressure and cholesterol. A diet based on fruit, vegetables and whole grains with one or two portions of fish per week (those rich in omega-3) has an undoubtedly beneficial effect on the cardiovascular system.
  3. Reduction of excess body weight . Being overweight increases the risk of coronary heart disease. Losing just a few pounds can help lower blood pressure and reduce the risk of coronary heart disease.
  4. Blood pressure control (ideal blood pressure is less than 140 as systolic and 90 as diastolic, measured in millimeters of mercury-mmHg).
  5. Cholesterol control . If the test results are not within the desirable values, the doctor may recommend more frequent measurements and specific dietary or pharmacological measures. Most people should aim for an LDL level below 130 milligrams per deciliter (mg / dL), 3.4 millimoles per liter (mmol / L). If you are suffering from other cardiovascular risk factors, LDL cholesterol should be less than 100 mg / dl (2.6 mmol / L).
  6. Control of fasting blood sugar levels and if you have fundamental diabetes mellitus, be followed up at a diabetes center.
  7. Manage stress by practicing healthy techniques for managing it, such as muscle relaxation and deep breathing.

drugs

There are numerous pharmacological aids that can be indicated in patients with chronic ischemic heart disease. The main ones are: drugs that reduce blood coagulability (antiplatelet agents such as aspirin, clopidogrel, ticagrelor), which reduce the need for blood to the heart and blood pressure (beta-blockers, calcium channel blockers, ACE inhibitors and sartanics) that can they dilate the coronary arteries (nitrates) and which reduce the levels of cholesterol and triglycerides (statins, Omega3, ezetinibe, fibrates).

Myocardial revascularization techniques

Although drug therapy is of primary importance in the treatment of chronic stable angina, however, it is sometimes not sufficient to guarantee symptomatic control. In these cases it is important to proceed with coronary angiography and percutaneous (with angioplasty) or surgical (with by-pass) myocardial revascularization.

Percutaneous coronary angioplasty (PTCA) with stent implant : This is a minimally invasive treatment performed under local anesthesia through the insertion of a small catheter inside an artery of the wrist (radial) or groin (femoral) which is traced back under radiographic guidance to the origin of the coronaries (hosts).

Once the coronary stenosis has been identified after contrast medium injection, a guide wire is positioned in the coronary downstream of the stenosis followed by the advancement of a balloon inflated in correspondence of the stenosis and by the subsequent implantation of a metallic “shirt” (stent) with or without drug release (medicated or non-medicated stent). The atherosclerotic plaque causing stenosis is then crushed against the artery wall and trapped on the outside of the stent. Usually this is a procedure that requires 2 days of hospitalization.

It is important to remember that after stent implantation a period of double anti-aggregation (cardioaspirin and clopidogrel) with a duration varying from one month (after non-medicated stent implantation) is necessary (in order to avoid an acute closure of the same with consequent heart attack) at 6-12 months (after medicated stent implantation).

The suspension of one of the antiplatelet agents for various reasons including the most frequent represented by the need for surgery will always be agreed and evaluated with the trusted cardiologist and if possible the intervention should be postponed to the end of the double antiplatelet period.

Coronary artery bypass graft

It is a major surgery treatment that requires general anesthesia. To date, it is mainly performed in cases of severe involvement of multiple coronaries and in diabetic patients. The cardiac surgeon uses arteries (mammary) and veins (saphenous) taken from the patient himself which are then sutured downstream of the narrowing (“bypassing” it) in such a way as to ensure adequate blood flow to the heart muscle.

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