Chronic Stable Angina

As mentioned earlier, the most common reason for angina is atherosclerosis, i.e. blockage in the main arteries supplying the heart. Atherosclerotic plaque is initially made of cholesterol deposits, then it becomes fibrosed and then eventually there is calcium deposition in them. It is present in the walls of the coronary arteries in initial stages and then it slowly grows inward in the vessel lumen. Progression of atherosclerosis is very slow and over many years to cause significant narrowing of the coronary arteries.

 

Differences between stable and unstable angina

As mentioned previously, CSA is chest pain or discomfort on exertion and subsides with rest or taking nitroglycerin. Unstable angina is quite different and is important to identify these patients as it is necessary to do coronary angiograms in these patients urgently to plan revascularization subsequently. Unstable angina is defined as chest pain or discomfort arising at rest or minimal discomfort, lasting for more than 15-20 minutes and/ or pain that has worsened over a short period of time.

4 main symptoms of angina are:

• Chest pain or discomfort, usually a sensation of heaviness
• Breathlessness
• Easy fatigability
• Palpitations

 

Risk Factors

• Modifiable risk factors -
• Hypertension i.e. raised blood pressure
• Hypercholesterolemia i.e. raised blood cholesterol levels
• Smoking
• Tobacco consumption
• Diabetes mellitus
• Obesity
• Sedentary Lifestyle
• Non-modifiable risk factors -
• Family history of heart problems
• Age

 

Microvascular Angina

It is a condition wherein the patient has symptoms of angina, but the major epicardial vessels of the heart show no significant narrowings (i.e. >50%). It is presumed due to narrowings of sub epicardial and other arteries distally in the coronary tree which are not seen via conventional angiography. This condition is more common in females, especially middle aged. Treatment of this condition is very difficult as conventional treatment for CSA is not very effective and lifestyle modification and good control of diabetes and hypertension is imperative for some symptomatic relief.

Medical management is the cornerstone for management of CSA. Guidelines say that optimum medical management is to be tried before attempting revascularization. If there is a proximal vessel disease then there is a debate with regards to earlier revascularization, rest optimal medical therapy is the preferred first line treatment for such patients.

 

Medications usually include:

• Aspirin or other anti platelet blood thinners
• Beta blockers like metaprolol, carvedilol or bisoprolol
• Long acting nitrates for angina control
• Other anti anginals like -Nicorandil, Ranolazine, Trimetazidine

 

Revascularization

• Intervention is performed in patients having symptoms despite optimal medical management or are intolerant to maximization of doses of medicines.
• PTCA with stenting or CABG is performed as need be, to achieve complete or maximal revascularization.

If CSA is not treated well, or more importantly if patients are not followed up at regular intervals, these patients can present with unstable angina or myocardial infarction (heart attack) and/ or reduction in the ejection fraction i.e. the pumping mechanism of the heart leading to heart failure.

Chronic stable angina, as the name suggests is a chronic condition of chest pain or discomfort most commonly due to atherosclerotic disease in the coronary arteries. It is imperative to diagnose this illness, treat it with effective medications and if need be, plan revascularization in the form of angioplasty or stenting.