Chronic Stable Angina

  • What Is Chronic Stable Angina?

    Coronary artery disease (CAD) can also be named coronary heart disease, coronary artery atherosclerosis, or stable ischaemic heart disease (SIHD) and is the major cause of death worldwide. It happens when there is an imbalance of blood supply to the myocardium caused by an atherosclerotic and ischaemic process in the coronary arteries1.

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    What Is Chronic Stable Angina?

    Coronary artery disease (CAD) can also be named coronary heart disease, coronary artery atherosclerosis, or stable ischaemic heart disease (SIHD) and is the major cause of death worldwide. It happens when there is an imbalance of blood supply to the myocardium caused by an atherosclerotic and ischaemic process in the coronary arteries1.

    Chronic stable angina pectoris is a well-known manifestation of CAD and is the first manifestation in 50% of CAD patients. It can double the risk of major cardiovascular (CV) events2.

    The precordial chest pain that characterises this condition usually appears with physical effort or emotional stress and is relieved by rest and/or nitroglycerin. However, when the symptoms occur at rest it is indicative of an unstable disease such as acute coronary syndromes2

    Signs and Symptoms

    The discomfort caused by an ischaemic process in the heart muscle is usually located in the chest, described as pressure, tightness, and heaviness, burning, or a constricting sensation. It is close to the sternum but can be felt in the epigastrium, lower jaw, or teeth, between the shoulder blades, or left arm. Shortness of breath can also be a symptom, along with chest discomfort3.

    Besides the typical precordial pain that can irradiate to the left arm or neck, many patients (mainly women and the elderly) can have atypical symptoms such as nausea, vomiting, midepigastric discomfort, fatigue, or sharp chest pain2,3

    Traditional clinical classification of suspected symptoms:

    Typical angina

    1. Meets the following three characteristics: 
    2. Constricting discomfort in the front of the chest in the neck, jaw, shoulder, or arm.
    3. Precipitated by physical exertion.
    4. Relieved by rest or nitrates within 5 minutes. 

    Atypical angina: 

    1. Meets two of these characteristics.
    2. Non-anginal chest pain.
    3. Meets only one or none of the typical angina characteristics cited above3.

    Grading of effort angina severity, according to the Canadian Cardiovascular Society 

    Grade description of angina severity:

    1. Angina only with strenuous exertion: presence of angina during strenuous, rapid, or prolonged ordinary activity (e.g. walking or climbing the stairs).
    2. Angina with moderate exertion: slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in the wind, under emotional stress, or during the first few hours after waking up; but also walking uphill, climbing more than one flight of ordinary stairs at a normal pace, and in normal conditions.
    3. Angina with mild exertion: having difficulties walking one or two ‘blocks’, or climbing one flight of stairs, at normal pace and in normal conditions.
    4. Angina at rest: no exertion needed to trigger angina3

    Unstable angina may present in one of three ways:

    1. Non-anginal chest pain.
    2. As rest angina, i.e. pain of characteristic nature and location occurring at rest and for prolonged periods (>20 min).
    3. New-onset angina, i.e. recent (2 months) onset of moderate-to-severe angina (Canadian Cardiovascular Society grade II or III).
    4. Crescendo angina, i.e. previous angina, which progressively increases in severity and intensity, and at a lower threshold, over a short period.

    Management of angina fulfilling these criteria is dealt with in the ESC Guidelines for the management of acute coronary syndromes3

    Diagnosis

    Coronary angiography is the gold standard for CAD diagnosis. Through a contrast material and x-rays, it shows how blood flows in the coronary arteries, defining the extent and severity of CAD. Patients with severe ischaemic symptoms and who do not benefit from guideline-directed medication therapy, as well as patients that cannot undergo stress testing, may benefit from this exam2.

    Treatment

    Lifestyle modification such as weight management, smoking cessation, and control of comorbidities such as diabetes, hypercholesterolemia, and high blood pressure is mandatory; besides drug therapy to relieve angina symptoms and to avoid ischaemic progression2.

    Medications to Prevent Myocardial Infarction and Death

    Antiplatelet therapy: dual antiplatelet therapy (DAPT) with aspirin and clopidogrel can provide additional benefits and may reduce CVEs and mortality.

    Beta-blockers: reduce myocardial oxygen consumption through a decrease in heart rate and myocardial contractility. 

    ACE inhibitors and angiotensin receptor b lockers (ARBs):  in addition to their established efficacy in the management of hypertension, ACE and ARB inhibitors can reduce atherosclerosis damage, having a protective effect on many CV conditions.
    Nitrates: are effective at managing all forms of angina and represent a first-line therapy for the management of acute anginal symptoms, by relaxing the vascular smooth muscle and reducing myocardial oxygen demand by inducing systemic vasodilation.

    Revascularisation surgery: this procedure aims to restore blood flow to the heart. Coronary artery bypass graft (CABG) and PCI are revascularisation procedures performed in patients to address SIHD, either for symptomatic relief or to improve survival. The Heart Team approach (i.e., multidisciplinary care) is recommended in patients with diabetes mellitus and complex multivessel diseases. For these patients, CABG is preferred to PCI to improve survival2.

    Prognosis 

    There is an annual mortality rate of up to 3.2%. 

    Refractory angina refers to symptoms that last for more than 3 months due to established reversible ischaemia in the presence of obstructive CAD, which cannot be controlled by escalating medical therapy with the use of: second- and third-line pharmacological agents; bypass grafting or stenting, including PCI of chronic total coronary occlusion3.

    Incidence is growing with more advanced CAD, multiple comorbidities, and aging of the population. The quality of life of these patients is poor, with frequent hospitalisation and a high level of resource utilisation3

    References

    1. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292.
    2. Management of Coronary Artery Disease and Chronic Stable Angina. Yesenia Camero, US Pharmacist. 2017;42(2):27-31. 
    3. Juhani Knuuti et al. ESC Scientific Document Group, 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC), European Heart Journal, Volume 41, Issue 3, 14 January 2020, Pages 407–477, https://doi.org/10.1093/eurheartj/ehz425.
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