Angina Pectoris notes according to the medicine lecture 20 mark question notes, medicine lecture with the clinical features, etiology, investigation, diagnosis, management, and with definition.
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Angina Pectoris — Medicine Lecture Notes (20 Marks)
1. DEFINITION
Angina pectoris is an episodic clinical syndrome of chest discomfort resulting from transient myocardial ischemia, produced when myocardial oxygen demand exceeds myocardial oxygen supply, without resulting in myocardial necrosis. The discomfort is typically described as heaviness, pressure, squeezing, smothering, or choking — only rarely as outright pain.
Harrison's Principles of Internal Medicine 22E, p. 2136
2. ETIOLOGY
Primary Cause
- Coronary artery disease (CAD) / Atherosclerosis — the most common cause; obstructive or stenotic coronary artery disease reduces oxygen delivery.
Other Cardiovascular Causes
- Coronary artery spasm (Prinzmetal/Variant angina)
- Microvascular dysfunction (Cardiac Syndrome X)
- Mural thrombosis at an atherosclerotic plaque
- Severe aortic stenosis or aortic regurgitation
- Hypertrophic obstructive cardiomyopathy (HOCM)
- Uncontrolled hypertension (increased wall stress)
- Severe anemia (reduced oxygen-carrying capacity)
Extracardiac Precipitants
- Fever, thyrotoxicosis (increased metabolic demand)
- Severe anemia, hypoxemia
- Hypertension
- Obesity, metabolic syndrome, type 2 diabetes
Pathogenetic Mechanisms
| Mechanism | Description |
|---|---|
| Demand angina | Increased myocardial O₂ demand (exertion, emotion, stress) in the setting of fixed coronary stenosis |
| Supply angina | Reduced O₂ delivery — vasospasm, thrombosis, microvascular disease |
Goldman-Cecil Medicine, block7; Harrison's, p. 2136
3. CLINICAL FEATURES
Symptoms
Classic presentation:
- Chest discomfort — central, substernal; described as heaviness, pressure, squeezing, smothering, tightness — rarely sharp pain
- Levine's sign — patient places a clenched fist over the sternum
- Duration — typically 2–5 minutes, crescendo-decrescendo pattern
- Radiation — to shoulders, arms (especially ulnar aspect of forearm and hand), neck, jaw, teeth, back, interscapular region, epigastrium
- Rarely localizes below the umbilicus or above the mandible
- Does not radiate to trapezius (more typical of pericarditis)
Precipitating factors:
- Physical exertion (climbing stairs, walking briskly, sexual activity)
- Emotional stress, anger, frustration, fright
- Cold exposure
- Heavy meals
- Morning peak of symptoms
Relieving factors:
- Rest (within 1–5 minutes)
- Sublingual nitroglycerin (within 1–5 minutes)
Special Patterns
| Pattern | Description |
|---|---|
| Stable (exertional) angina | Fixed threshold; reproducibly provoked by a predictable level of effort; relieved by rest |
| Unstable angina | New onset, crescendo angina, or rest angina; worsening frequency/severity |
| Variant (Prinzmetal) angina | Occurs at rest, caused by coronary vasospasm; ST elevation on ECG during attack |
| Angina decubitus | Occurs lying down; due to increase in end-diastolic volume, wall tension, and O₂ demand |
| Nocturnal angina | Awakens patient from sleep; related to episodic tachycardia or recumbent hemodynamic changes |
| Microvascular (Syndrome X) | Angina with normal coronary arteries; microvascular dysfunction |
Atypical Presentations
- More common in women, elderly, and diabetics
- May present as dyspnea, fatigue, or epigastric discomfort only
Physical Examination
- Often normal between episodes
- During an attack: transient S₄ gallop, paradoxical splitting of S₂, mitral regurgitation murmur (papillary muscle dysfunction), precordial bulge
- Signs of atherosclerosis: xanthelasma, arcus senilis, carotid bruits, absent peripheral pulses
- Signs of risk factors: hypertension, obesity
Harrison's, pp. 2136–2138; Goldman-Cecil Medicine, block7
4. INVESTIGATIONS
Routine Blood Tests
| Test | Purpose |
|---|---|
| CBC | Detect anemia (aggravates angina) |
| Fasting blood glucose / HbA1c | Diagnose/exclude diabetes |
| Lipid profile (total cholesterol, LDL, HDL, TG) | Identify dyslipidemia — key risk factor |
| Thyroid function tests | Rule out thyrotoxicosis |
| Renal function | Baseline before medications |
| Cardiac enzymes (Troponin I/T) | Exclude ACS/MI — normal in stable angina |
| CRP / hsCRP | Inflammatory marker; prognostic value |
Electrocardiogram (ECG)
- Resting ECG — often normal in stable angina; may show LVH, ST changes, Q waves (old MI), LBBB
- ECG during an attack — ST depression (demand ischemia), T-wave inversion
- Variant angina — ST elevation during episode (vasospasm)
Stress Testing
| Test | Indication |
|---|---|
| Exercise ECG (Treadmill test) | Standard first-line; positive if ≥1 mm horizontal/down-sloping ST depression |
| Stress echocardiography | Better sensitivity/specificity; detects wall motion abnormalities; preferred when resting ECG abnormal |
| Nuclear stress test (SPECT/PET) | Myocardial perfusion imaging; detects ischemia and viability |
| Pharmacological stress test (dobutamine, adenosine) | For patients unable to exercise |
Imaging
| Test | Purpose |
|---|---|
| Chest X-ray | Assess heart size, pulmonary congestion, aortic calcification |
| Echocardiogram (resting) | LV function (EF), wall motion, valve disease, LVH |
| CT Coronary Angiography (CTCA) | Non-invasive; rules out significant CAD; calcium scoring |
| Coronary Angiography (Cardiac Cath) | Gold standard — defines anatomy, stenosis severity; required before revascularization |
| MRI / CMR | Viability assessment, microvascular disease |
Harrison's, pp. 2138–2143; Goldman-Cecil Medicine, block7
5. DIAGNOSIS
Diagnostic Criteria
Angina pectoris is primarily a clinical diagnosis based on history. The three classic features (Diamond-Forrester classification):
| Type | Criteria Met |
|---|---|
| Typical (definite) angina | All 3: substernal chest discomfort + provoked by exertion/stress + relieved by rest or nitrates |
| Atypical angina | 2 of 3 features |
| Non-cardiac chest pain | 0–1 features |
CCS Grading Scale (Canadian Cardiovascular Society)
| Class | Description |
|---|---|
| I | Angina only with strenuous or prolonged exertion; ordinary activity does not cause angina |
| II | Slight limitation of ordinary activity; angina on walking >2 blocks, climbing >1 flight of stairs |
| III | Marked limitation of ordinary activity; angina on walking 1–2 blocks or climbing 1 flight |
| IV | Inability to perform any activity without angina; angina may be present at rest |
Differential Diagnosis
- Cardiovascular: ACS, pericarditis, aortic dissection
- Pulmonary: Pulmonary embolism, pleuritis, pneumothorax
- GI: GERD, esophageal spasm (can closely mimic angina), peptic ulcer, biliary colic
- Musculoskeletal: Costochondritis, chest wall pain (reproducible by palpation — argues against angina)
- Other: Anxiety/panic attack, herpes zoster
Harrison's, pp. 2136–2138
6. MANAGEMENT
A. General Measures / Risk Factor Modification
- Smoking cessation — accelerates atherosclerosis, increases thrombotic risk, reduces O₂ supply; most important modifiable risk factor
- Weight reduction — achieves optimal BMI; reduces associated DM, HTN, dyslipidemia
- Dietary modification — low saturated/trans fat, low calorie, Mediterranean diet
- Regular aerobic exercise — improves coronary collateral circulation; cardiac rehabilitation
- Strict glycemic control in diabetics
- Blood pressure control (target <130/80 mmHg)
- Lipid management — statins are cornerstone (target LDL reduction)
- Avoid precipitating factors — heavy meals, cold, emotional stress
B. Pharmacological Management
1. Anti-Anginal Drugs
| Drug Class | Mechanism | Examples | Notes |
|---|---|---|---|
| Nitrates (sublingual) | Venodilation → reduced preload; coronary vasodilation | GTN (nitroglycerin) | For acute attack; onset 1–3 min; give at rest, seated |
| Nitrates (long-acting) | Sustained venodilation | Isosorbide mononitrate/dinitrate | Prophylaxis; nitrate-free interval (8h) to avoid tolerance |
| Beta-blockers | Reduce heart rate & contractility → ↓ O₂ demand; first-line | Metoprolol, Atenolol, Bisoprolol | Cardioselective preferred; avoid in vasospastic angina; target HR 55–60 bpm |
| Calcium Channel Blockers (CCBs) | Vasodilation + ↓ heart rate/contractility | Amlodipine (DHP); Diltiazem, Verapamil (non-DHP) | DHP for exertional angina; non-DHP avoid with beta-blockers (bradycardia risk); drug of choice in Prinzmetal angina |
| Ranolazine | Inhibits late INa → ↓ intracellular Ca²⁺ overload | Ranolazine | Add-on therapy; no hemodynamic effects; useful in patients intolerant to beta-blockers |
| Ivabradine | Selective If channel inhibitor → ↓ HR | Ivabradine | For patients in sinus rhythm intolerant to beta-blockers |
2. Antiplatelet Therapy (Cardioprotective)
- Aspirin 75–150 mg daily — first-line antiplatelet; reduces risk of MI and death in stable CAD
- Clopidogrel — alternative if aspirin contraindicated; also post-PCI
3. Statins (HMG-CoA Reductase Inhibitors)
- All CAD patients regardless of baseline LDL — plaque stabilization + lipid lowering
- Examples: Atorvastatin 40–80 mg, Rosuvastatin 20–40 mg (high-intensity therapy)
4. ACE Inhibitors / ARBs
- Indicated in patients with concurrent heart failure, LV dysfunction, diabetes, or hypertension
- Examples: Ramipril, Perindopril, Lisinopril
5. Management of Acute Attack
- Patient sits or lies down
- Sublingual GTN (glyceryl trinitrate) 0.3–0.5 mg; may repeat every 5 min × 3 doses
- If no relief after 15 min → call emergency (suspect ACS/NSTEMI)
C. Revascularization
1. Percutaneous Coronary Intervention (PCI)
- Coronary angioplasty ± stent (drug-eluting stent preferred)
- Indicated for significant single or multivessel disease, failed medical therapy
- Choice for focal stenosis; good for symptoms relief
2. Coronary Artery Bypass Grafting (CABG)
- Indicated for:
- Left main coronary artery disease (>50% stenosis)
- Triple vessel disease (especially with reduced EF)
- Diabetics with multivessel disease
- Failed PCI
- Superior to PCI for survival benefit in complex multivessel CAD and LV dysfunction
Harrison's, pp. 2139–2148; Goldman-Cecil Medicine, block7
7. SUMMARY TABLE
| Aspect | Key Points |
|---|---|
| Definition | Transient myocardial ischemia → chest discomfort; supply-demand mismatch |
| Most common cause | Atherosclerotic CAD |
| Classic symptom | Substernal pressure/heaviness, 2–5 min, provoked by exertion, relieved by rest/GTN |
| Radiation | Left arm (ulnar), jaw, neck, back; never trapezius |
| Levine's sign | Clenched fist over sternum |
| Gold standard investigation | Coronary angiography |
| First-line anti-anginal | Beta-blocker (with aspirin + statin) |
| Acute attack drug | Sublingual GTN |
| Prinzmetal angina drug | Calcium channel blocker |
| Revascularization | PCI (single/double vessel); CABG (left main, triple vessel, diabetics) |
| CCS Class IV | Angina at rest — unstable; urgent intervention needed |
Sources:
- Harrison's Principles of Internal Medicine 22E (2025, McGraw Hill Medical), Chapter 284
- Goldman-Cecil Medicine International Edition, Chapter 39
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