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What is the definition of chronic angina?
Traditionally, chronic angina is a clinical syndrome characterized by discomfort
in the chest, jaw, shoulder, back, or arm of minutes in
duration.5 It is visually characterized as the Levine
Sign (ie, a hand clutching the chest).6 Chronic angina is typically aggravated by
exertion or emotional stress and relieved by rest and/or
nitroglycerin.5
Atypical symptoms, known as anginal equivalents, have also been described and
are more likely to occur in women or the elderly. Atypical symptoms can
include
dyspnea localized to the mid-chest, in addition to discomfort
in the lower
jaw, teeth, neck, shoulders, ulnar aspect of the
left arm, indigestion,
dizziness, and diaphoresis.6
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What is myocardial ischemia?
Myocardial ischemia is an imbalance between oxygen supply and demand in the heart that can lead to symptoms of chronic angina. The amount of oxygen-rich blood available to the heart depends on coronary blood flow and the
oxygen-carrying capacity of the blood. Coronary blood flow is influenced by the amount of atherosclerotic plaque of coronary artery disease, vasospasm, presence of a thrombus, or length of diastole.7 The epicardial arteries and the microvasculature make up the coronary flow reserve. There is very little reserve in the microvasculature to compensate for increased supply and demand. Under normal conditions, the reserve is four to six times the basal flow.8 During periods of physical exertion or emotional stress, myocardial demand in excess of the reserve can result in myocardial ischemia.7 Many patients may experience angina pain or discomfort (eg, in the chest, jaw, shoulder, back, or arm of minutes in duration) that resolves with rest and/or sublingual nitroglycerin.5 However, signs of chronic angina are not necessarily restricted to the classic Levine sign (ie, a hand clutching the chest). Anginal equivalents (eg, dyspnea localized to the mid-chest), in addition to discomfort in the lower jaw, teeth, neck, shoulders, ulnar aspect of the left arm, indigestion, dizziness, and diaphoresis) may be reported, usually more often in women and the elderly.6 Myocardial ischemia may not always reach the crescendo of an angina attack.7,9 While myocardial ischemia may be detectable with electrocardiographic monitoring, it is physically imperceptible to approximately 50% of patients (ie, silent ischemia).10
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How prevalent is chronic angina?
According to the American Heart Association, approximately 8.9 million Americans
have angina, and at least 400,000 new cases are reported annually.11 Chronic angina is the most common
manifestation of ischemic heart disease (IHD), and the first manifestation of
IHD in at least half of patients.5
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Do patients with chronic angina often have other comorbidities?
Yes, comorbidities in patients with chronic angina are common. In the Euro Heart Survey of Stable Angina (N=3779, 42% female), other comorbidities included hypertension (61%), hyperlipidemia (57%), and diabetes (18%).12
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What is the goal of treatment for the symptoms of chronic angina?
According to the most recent American College of Cardiology/American Heart Association guidelines for the management of symptoms of chronic angina, patients should be able to return to their usual activities with either no angina chest pain or discomfort, or with minimal symptoms.Ideally, patients’ functional capacities should be advanced to Canadian Cardiovascular Society (CCS) I, meaning usual activities such as walking or climbing the stairs do not elicit an angina attack. Patients should be allowed to participate in the individualization of their therapy as based on their clinical presentation, and adverse effects related to therapy should be minimal.5
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How have patients with chronic angina been routinely managed?
Beta-blockers, calcium channel blockers, and nitrates are the drug classes that have been used for the symptoms of chronic angina. Revascularization options include percutaneous coronary intervention (PCI) with or without a stent, or coronary artery bypass grafting (CABG). Other less traditional options if other treatments fail include enhanced external counterpulsation (EECP), transmyocardial revascularization (TMR), or spinal cord stimulation (SCS).5
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