Angina Pectoris Overview

If you are having pain or pressure in the middle of your chest, left neck, left shoulder, or left arm, go
immediately to the nearest hospital emergency department. Do not drive yourself. Call 911 for emergency
transport.

Angina, or angina pectoris, is the medical term used to describe the temporary chest discomfort that occurs when the
heart is not getting enough blood.

 The heart is a muscle (myocardium) and gets its blood supply from the coronary arteries. 

 Blood carries the oxygen and nutrients the heart muscle needs to keep pumping. 

 When the heart does not get enough blood, it can no longer function at its full capacity. 

 When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the
heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in
the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by
removing the stressor and/or taking sublingual (under the tongue) nitroglycerin. 

 The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day.

An episode of angina is not a heart attack. Having angina means you have an increased risk of having a heart attack.

 A heart attack is when the blood supply to part of the heart is cut off and that part of the muscle dies
(infarction). 

 Angina can be a helpful warning sign if it makes the patient seek timely medical help and avoid a heart
attack. 

 Prolonged or unchecked angina can lead to a heart attack or increase the risk of having a heart rhythm
abnormality. Either of those could lead to sudden death.

Time is very important in angina.

 The more time the heart is deprived of adequate blood flow (ischemia), and thus oxygen, the more the
heart muscle is at risk of heart attack or heart rhythm abnormalities. 

 The longer the patient experiences chest pain from angina, the more the heart muscle is at risk of dying or
malfunctioning.

Not all chest pain is angina. Pain in the chest can come from a number of causes, which range from not serious to
very serious.

 For example, chest pain can be caused by:

o acid reflux (gastroesophageal reflux disease, GERD), 

o upper respiratory infection, 

o asthma, or

o sore muscles and ligaments in the chest (chest wall pain)

 If chest pain is severe and/or recurrent, the patient should see a healthcare provider. 

 Go to a hospital emergency department if the patient has any of the following with chest pain: 

o Other symptoms such as:

 sweating,

 weakness,

 faintness, 
  numbness or tingling, or 

 nausea 

o Pain that does not go away after a few minutes 

o Pain that is of concern in any way

Angina Pectoris Causes

Angina is classified as one of the following two types:

 Stable angina 

 Unstable angina

Stable Angina

Stable angina is the most common angina, and the type most people mean when they refer to angina.

 People with stable angina usually have angina symptoms on a regular basis. The episodes occur in a
pattern and are predictable. 

 For most people, angina symptoms occur after short bursts of exertion. 

 Stable angina symptoms usually last less than five minutes. 

 They are usually relieved by rest or medication, such as nitroglycerin under the tongue.

Unstable Angina

Unstable angina is less common. Angina symptoms are unpredictable and often occur at rest.

 This may indicate a worsening of stable angina, but sometimes the first time a person has angina it is
already unstable. 

 The symptoms are worse in unstable angina - the pains are more frequent, more severe, last longer, occur
at rest, and are not relieved by nitroglycerin under the tongue. 

 Unstable angina is not the same as a heart attack, but it warrants an immediate visit to the healthcare
provider or a hospital emergency department. The patient may need to be hospitalized to prevent a heart attack.

If the patient has stable angina, any of the following may indicate worsening of the condition:

 An angina episode that is different from the regular pattern 

 Being awakened at night by angina symptoms 

 More severe symptoms than usual 

 Having angina symptoms more often than usual 

 Angina symptoms lasting longer than usual

Coronary Heart Disease

The most common cause for the heart not getting enough blood is coronary heart disease, also called coronary artery
disease.

 In this disease, the coronary arteries become blocked, narrowed, or otherwise damaged. 

 They can no longer supply the heart with all of the blood it needs.

Most cases of coronary heart disease are caused by atherosclerosis (hardening of the arteries).
 Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels. 

 These buildups are called plaques, and they can block blood flow through the vessels partially or
completely. Multiple risk factors, particularly:

o diabetes,

o high blood pressure,

o smoking,

o high cholesterol, and 

o genetic predisposition may accelerate this build up.

Coronary Artery Spasm

Another cause of unstable angina is coronary artery spasm.

 Spasm of the muscles surrounding the coronary arteries causes them to narrow or close off temporarily.
This blocks the flow of blood to the heart muscle for a brief time, causing angina symptoms. 

 This is called variant angina or Prinzmetal angina. 

 This is not the same as atherosclerosis, although some people have both conditions. 

 The symptoms often come on at rest (or during sleep) and without apparent cause.

 Cocaine use/abuse can cause significant spasm of the coronary arteries and lead to a heart attack.

Other Causes

Other causes of angina symptoms include the following:

 Blockage of a coronary artery by a blood clot or by compression from something outside the artery 

 Inflammation or infection of the coronary arteries 

 Injury to one or more coronary arteries 

 Poor functioning of the tiny blood vessels of the heart (microvascular angina)

When a person has underlying atherosclerosis, spasm, or damage to the coronary arteries, angina symptoms usually
are set off by one of the following triggers:

 Physical exertion or exercise 

 Emotional stress 

 Exposure to cold

 Decreased oxygen content in the air you breathe (for example flying in an airplane or at high altitudes) 

 Using a stimulant such as caffeine or smoking cigarettes (which lowers the amount of oxygen in the blood)

Risk Factors for Atherosclerosis and Angina

Risk factors for atherosclerosis and angina include the following. Some of these are reversible.

 High blood pressure (hypertension) 

 High levels of cholesterol and other fats in the blood 

 Diabetes 

 Smoking 
 Male gender 

 Inactive (sedentary) lifestyle 

 Family history of coronary heart disease 

 Aging 

 Regular use of stimulants, especially nicotine, cocaine, or amphetamines: Other stimulants include

Angina Pectoris Symptoms

Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:

 An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest 

 It may also feel like tightness, burning, or a heavy weight. 

 The pain may spread to the shoulders, neck, or arms. 

 It may be located in the upper abdomen, back, or jaw. 

 The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack, as follows:

 Shortness of breath 

 Lightheadedness 

 Fainting 

 Anxiety or nervousness 

 Sweating or cold, sweaty skin 

 Nausea 

 Rapid or irregular heart beat 

 Pallor (pale skin) 

 Feeling of impending doom

These symptoms are identical to the signs of an impending heart attack described by the American Heart
Association. It is not always easy to tell the difference between angina and a heart attack, except angina only lasts a
few minutes and heart attack pain does not go away.

 If you have never had symptoms like this before, sit down. If you are able, call your healthcare  provider,
call 911, or go to the closest hospital emergency department. 

 If you have had angina attacks before and this attack is similar to those, rest for a few minutes. Take your
sublingual nitroglycerin. Your angina should be totally relieved in five minutes. If not, you may repeat the
nitroglycerin dose and wait another five minutes. A third dose may be tried but if you still have no relief, call 911 or
go to the nearest hospital emergency department.

Stroke 

Definition
A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.

Description
A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply oxygen and nutrients and
to remove waste products, brain cells quickly begin to die. Depending on the region of the brain affected, a stroke
may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death. A stroke also is
sometimes called a brain attack or a cerebrovascular accident (CVA).

Some important stroke statistics include:

 more than one-half million people in the United States experience a new or recurrent stroke each year
 stroke is the third leading cause of death in the United States and the leading cause of disability
 stroke kills about 160,000 Americans each year, or almost one out of three stroke victims
 three million Americans are currently permanently disabled from stroke
 in the United States, stroke costs about $30 billion per year in direct costs and loss of productivity
 two-thirds of strokes occur in people over age 65 but they can occur at any age
 strokes affect men more often than women, although women are more likely to die from a stroke

 strokes affect blacks more often than whites, and are more likely to be fatal among blacks

Stroke is a medical emergency requiring immediate treatment. Prompt treatment improves the chances of survival
and increases the degree of recovery that may be expected. A person who may have suffered a stroke should be
seen in a hospital emergency room without delay. Treatment to break up a blood clot, the major cause of stroke, must
begin within three hours of the stroke to be effective. Improved medical treatment of all types of stroke has resulted in
a dramatic decline in death rates in recent decades. In 1950, nine in ten died from stroke, compared to slightly less
than one in three in the twenty-first century. However, about two-thirds of stroke survivors will have disabilities
ranging from moderate to severe.

Causes and symptoms

Causes
There are four main types of stroke. Cerebral thrombosis and cerebral embolism are caused by blood clots that block
an artery supplying the brain, either in the brain itself or in the neck. These account for 70-80% of all
strokes. Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the
brain.

Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the flow of blood
through the affected vessel. Clots most often form due to "hardening" (atherosclerosis) of brain arteries. Cerebral
thrombosis occurs most often at night or early in the morning. Cerebral thrombosis is often preceded by a transient
ischemic attack, or TIA, sometimes called a "mini-stroke." In a TIA, blood flow is temporarily interrupted, causing
short-lived stroke-like symptoms. Recognizing the occurrence of a TIA, and seeking immediate treatment, is an
important step in stroke prevention.

Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free. If it becomes
lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke. The most common
cause of cerebral embolism is atrial fibrillation, a disorder of the heart beat. In atrial fibrillation, the upper chambers
(atria) of the heart beat weakly and rapidly, instead of slowly and steadily. Blood within the atria is not completely
emptied. This stagnant blood may form clots within the atria, which can then break off and enter the circulation. Atrial
fibrillation is a factor in about 15% of all strokes. The risk of a stroke from atrial fibrillation can be dramatically reduced
with daily use of anticoagulant medication.

Hemorrhage, or bleeding, occurs when a blood vessel breaks, either from trauma or excess internal pressure. The
vessels most likely to break are those with preexisting defects such as an aneurysm. An aneurysm is a "pouching
out" of a blood vessel caused by a weak arterial wall. Brain aneurysms are surprisingly common. According
to autopsy studies, about 6% of all Americans have them. Aneurysms rarely cause symptoms until they burst.
Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important
preventive strategy.

Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the
brain's surface, just below the protective arachnoid membrane. Intracerebral hemorrhages represent about 10% of all
strokes, while subarachnoid hemorrhages account for about 7%.

In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates
excess pressure on brain tissue, which can quickly become fatal. Nonetheless, recovery may be more complete for a
person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects usually are
not as severe.

Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells.
This is one reason why prompt treatment can have such a dramatic effect on final recovery.

Risk factors
Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, use of certain
medications, and lifestyle choices:

 Age and sex. The risk of stroke increases with age, doubling for each decade after age 55. Men are more
likely to have a stroke than women.
 Heredity. Blacks, Asians, and Hispanics have higher rates of stroke than do whites, related partly to higher
blood pressure. People with a family history of stroke are at greater risk.
  Diseases. Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation), high
blood pressure, prior stroke, or TIA. Risk of stroke increases tenfold for someone with one or more TIAs.
 Other medical conditions. Stroke risk increases with obesity, high blood cholesterol level, or high red blood
cell count.
 Hormone replacement therapy. In mid-2003, a large clinical trial called the Women's Health Initiative was
halted when researchers discovered several potentially dangerous effects of combined hormone
replacement therapy on postmenopausal women. In addition to increasing the risk of some cancers
anddementia, combined estrogen and progesterone therapy increased risk of ischemic stroke by 31%
among study participants.
 Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use oforal
contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use
of cocaine or intravenous drugs.

Symptoms
Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start,
while symptoms of a thrombotic stroke come on more gradually. Symptoms may include:

 blurring or decreased vision in one or both eyes

Diagnosis
The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of
symptoms, presence of risk factors, and the exclusion of other possible causes. A brief neurological exam is
performed to identify the degree and location of any deficits, such as weakness, incoordination, or visual losses.

Once stroke is suspected, a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is
performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that
guides therapy. Blood and urine tests are done routinely to look for possible abnormalities.

Other investigations that may be performed to guide treatment include an electrocardiogram, angiography,

Treatment

Emergency treatment
Emergency treatment of stroke from a blood clot is aimed at dissolving the clot. This "thrombolytic therapy" currently
is performed most often with tissue plasminogen activator, or t-PA. t-PA must be administered within three hours of
the stroke event. Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of
onset cannot be accurately determined. t-PA therapy has been shown to improve recovery and decrease long-term
disability in selected patients. t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not
appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of
intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months.
Patients with clot-related (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with
heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases.

Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or
mannitol plus hyperventilation is the most common treatment. Corticosteroids also may be used. Patients with
reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders
reversed, if possible.

Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to
allow access. Ruptured vessels are closed off to prevent rebleeding. For aneurysms that are difficult to reach
surgically, endovascular treatment may be used. In this procedure, a catheter is guided from a larger artery up into
the brain to reach the aneurysm. Small coils of wire are discharged into the aneurysm, which plug it up and block off
blood flow from the main artery.