Angina pectoris:

Angina pectoris can be diagnosed without technical devices; the decisive point is the history. The term "Angina pectoris" does not include every "feeling of tightness in the chest," but automatically steers suspicion toward a diagnosis of coronary heart disease when the possibility of stenosis of the aortic valve is out of question. Independent of how the presence of coronary heart disease was determined, be it through coronary angiography and/or a heart attack, a diagnosis of Angina pectoris should always be taken very seriously. I. Angina pectoris with coronary heart disease 1. Stable Angina The classic case of Angina pectoris is characterized by a stress-dependent, retrosternal feeling of pressure, lasting from seconds to several minutes; the sensation can radiate into the neck, lower jaw, left arm and back. Precordial sensations that radiate into the left arm are often signified as "atypical," but are in any case to be taken seriously when they are stress dependent and reproducible. Typical for Angina pectoris is fast (within minutes) response to sublingually applied nitroglycerin or isosorbide dinitrate. Diagnostics: The guidelines for obligatory and optional diagnostic measures regarding Angina pectoris are controversial. Some cardiologists principally prescribe coronary angiography (Arrow A), when no other reasons, such as age, poor patient condition or another illness contraindicate such a procedure. Other cardiologists advocate using coronary angiography only with objective proof of ischemia (ECG after work, stress echocardiography, myocardial scintigraphy) (Arrow B).   Nevertheless, a rationally founded recommendation for treatment in the individual patient (drug therapy, PTCA or bypass surgery) can only be made following a cardiac catheter examination.   2. Unstable Angina A diagnosis of unstable Angina pectoris is always to be taken very seriously. The patient must be monitored without delay and should have a coronary angiography performed as soon as possible. Angina pectoris is termed "unstable" when formerly stable Angina pectoris is experienced more often and/or more intensely without external causes (a change in blood pressure adjustment, omission of medication, increased psychosocial pressure). Particularly Angina pectoris occurring while at rest can be seen as the threat of a heart attack or an acute infarct. In the past, so-called "recent onset" Angina, i.e. Angina whose onset occurred within the last 4 weeks, was regarded as unstable. Recently, this concept is being disregarded. A newcomer in the diagnostic scene is Postinfarct Angina, which is Angina pectoris following a heart attack (with or without thrombolysis); it is to be taken very seriously and is associated with increased risk of reinfarction.       II. Special cases involving Angina pectoris These cases can only be diagnosed by performing a cardiac catheter examination: 1. Angina with normal coronary arteries This constellation is rare, but generally recognized as an illness. If the ECG after work is pathological, we speak of "Syndrome X." Perfusion abnormalities and still missing inducible irregular muscle wall movements cause the myocardial scintigraphy to be pathological more often than the ECG after work. A further (at present still mostly scientifically indicated) examination is the determination of the coronary flow reserve, predominantly with administration of acetylcholine (endothelium dependent reaction) and adenosine (or dipyridamole) or nifedipine (endothelium independent reaction). Coronary flow reserve used to be determined using the Argon noble gas method, which has in present times been replaced with the invasive Doppler flow measurement. Calcium antagonists are used for treatment, recently aminophylline or L-arginine, too.   2. Angina with coronary spasms This disturbance is also rare, but can be dangerous. Diagnosis is based on classic Angina pectoris localization, but without the stress-dependent triggering modus. Angina pectoris onset is often spontaneous and occurs at the same times every day. A coronary angiogram shows no irregularities; provocation tests (ergotamine derivatives, acetylcholine) may be positive, but are insensitive and unspecific. The diagnosis is confirmed with an ECG recorded during an episode and showing distinct changes in S-T segments (this often requires several long-term ECG monitorings; an alternative is electronic short-term memory, e.g. a loop recorder). Therapeutically, an exception can be made: several calcium antagonists may be combined; in rare cases, a PTCA with stent implantation can help.   The medication administered is anti-anginal/anti-ischemic. The basic drug should as a rule be a nitrate (e.g. ISDN-retard) taken in combination with a beta blocker or a frequency-lowering calcium antagonist (verapamil-type). In rare cases, a third medication may be required in the combination, but then a PTCA or bypass surgery should be primarily considered.

Author: Sigmund Silber, MD; published in German in Medizin im Bild, 3/1997, pp. 43-44.