Best Angina Pectoris Treatment Hospital in Hyderabad, India

Angina pectoris diagnosis includes a combination of medical history, physical examination, and some diagnostic tests. The following are the steps involved in diagnosing angina: 

🔷Diagnostic evaluation of angina pectoris​

The cardiologist considers the following before selecting the appropriate tests to diagnose angina: 

• Medical history: The physician will inquire about the presenting symptoms and risk factors. The patient's complete family history and previous medical history are also taken to determine whether the chest pain or discomfort is due to angina or other causes.

• Physical examination: During physical examination, the physician will measure blood pressure and heart rate, will listen to the heart and lungs, will check pulse, and will record the body temperature.

🔷Diagnostic test for angina pectoris​

Based on the above information the cardiologist may recommend for following diagnostic tests: 

• Chest X ray: This test helps in ruling out other causes of chest discomfort and pain. Alone is not enough to diagnose angina, it helps in screening of lung disorder and pneumonia. It shows indications and signs of an enlarged heart which could be connected to Coronary artery disease (CAD). Certain conditions which relates to the lungs can be visualized by using ECG. 

• Electrocardiogram (ECG): Electrocardiogram records the electrical activity of the heart. It is used in diagnosing heart related abnormalities such as arrythmias and ischemia. ECG patterns are signs of unstable angina and vasospastic angina whereas ECG readings are normal in stable angina. The ECG profile in patients with angina pectoris is variate. It provides valuable information for both diagnosis and prognosis, especially when a tracing is obtained during the episodes of chest pain. If taken out in the presence of pain it may assist in clarifying the differential diagnosis. The resting ECG has an important role in risk stratification.

• Laboratory testing: Basic lab testing is performed including complete blood count and basic metabolic profile to measure the levels of cardiac troponin (a protein that is present in heart muscles). Along with this, blood glucose and cholesterol levels are also measured. 

• Stress tests: Stress tests help to know how well the heart is working when it is pumping hard. This test is performed during exercise on a treadmill or stationary bicycle. These tests also take images of the heart at rest and when it's working hard thereby providing detail about how well the heart is working. During stress testing the heart is monitored by imaging studies during an episode of increased cardiac demand in order to identify ischemic areas. The cardiac demand for stress testing is increased by exercise or by drugs (pharmacologic). In exercise stress testing the cardiac demand is increased by making the patient walk on a conventional treadmill, until the target heart rate is reached, or symptoms occur. In pharmacologic stress testing certain drugs are administered to patients to increase the cardiac demand and it is for patients who cannot walk on a treadmill long enough due to their health condition.

Other diagnostic studies 

• Echocardiogram: This test helps in examining how well the heart is pumping blood to various parts of the body. It helps in diagnosing blood clots and damaged heart valves. This test uses ultrasound waves in order to create detailed images of the heart and the surrounding organs. Blood flow to the heart can be determined by echocardiography. 

• Cardiac magnetic resonance imaging: The aim of this diagnostic test is to determine the blood flow to the heart muscles. It is an ideal noninvasive modality for assessing and diagnosing angina patients. This imaging test uses a magnetic field and radiofrequency waves to create detailed pictures of heart and arteries. It is often indicated in individuals who have advanced or complex heart conditions and are often suggested after initial first-line testing, such as transthoracic echocardiography.

• Coronary computed tomography (CT) angiography: It is a diagnostic test that creates detailed 3D images of the arteries in heart and detects abnormalities, determines blood flows and to diagnose cardiovascular disease. A nontoxic contrast dye is injected in patients who are undergoing a coronary computed tomography angiography in order to make blockages and other abnormalities more visible. It can also determine any type of heart disease, including heart structure or aortic abnormalities.

• Invasive coronary angiography: This test is indicated in angina with a high suspicion for significant coronary artery disease, often based on a prior non-invasive investigation that includes exercise stress testing, and coronary computed tomography angiography (CTCA). In this test, a thin tube, called a cardiac catheter is inserted into an artery in the wrist or groin under local anesthesia. The cardiac catheter is then moved to the coronary arteries followed by an injection of contrast dye which enables visibility of significant narrowing or blockages.
  

Differential diagnosis is a process of differentiating two diseases with similar signs and symptoms. In angina the differential diagnosis is divided into body systems as follows:

Gastrointestinal: Gastroesophageal reflux disease (GERD), hiatal hernia and peptic ulcer disease (PUD).

• Musculoskeletal: Costochondritis (inflammation of the cartilage that connects ribs to the breastbone), rib injury, muscle spasm, chest wall injury.

• Pulmonary: Pneumothorax (condition in which air leaks from the lungs into the space between the chest wall and lungs), pneumonia, pulmonary embolism. 

• Psychiatric: Panic attack and generalized anxiety

• Vascular: Aortic dissection

• Cardiac non-ischemic: Pericarditis (inflammation of pericardium which is a thin sac-like structure surrounding the heart), myocarditis (inflammation of myocardium or muscles of the heart).
  

Angina is the common presentation of coronary artery disease, and it requires multifactorial treatment which involves lifestyle changes, risk factor modification and medical therapy. The primary goals of angina treatment include: 



• To relief symptoms
• To prevent disease progression or slowing of disease progression
• To prevent future cardiac events such as myocardial infarction (MI)
• And to improve survival.
  

Angina pectoris treatment is aimed at managing symptoms as well as slowing progression to cardiac events. The essential components of angina treatment include lifestyle modification, risk factor modification, and medical therapy. Revascularization may be considered in cases where the symptoms are refractory to medical therapy. Treatment usually involves two approaches; one is to increase the blood flow to the heart muscles and the other is to lower the workload of heart.

🔷Non-pharmacological management of angina

When the symptoms are stable and not getting worse, than angina can be managed with certain lifestyle modifications or changes. Below are some of the measures listed by following which angina can be managed: 

• Diet: Choosing a diet that is heart healthy and includes fruits, vegetables, lean meat, and high fiber can decrease high blood pressure, and high cholesterol which in turn helps in easing angina symptoms. Limiting alcohol consumption and avoiding large meals. 

• Body weight: Maintaining a healthy or ideal body weight helps in preventing risk factors of angina. If overweight or obese, create a weight loss plan and follow a diet recommended by a nutritionist in order to prevent further progression of angina. 

• Being physically active: Regular physical activity can help in losing weight, reduce risk factors of heart disease, and improve physical fitness. Moderate aerobic exercise is recommended. 

• Managing stress: Many studies indicate that an emotionally upset event can trigger a heart attack or angina in some individuals. Managing stress is important as stress can contribute to high blood pressure and develop the risk of heart disease. 

• Avoiding smoking: Smoking worsens angina by damaging and tightening the blood vessels. It can also raise the risk of life-threatening complications. Therefore, smoking cessation is important to prevent the risk of heart disease. 

• Getting enough sleep: Sleep can heal and repair heart muscles. Not sleeping enough for long periods can increase the risk of heart disease. Therefore, getting enough sleep is important to maintain a balance of hormones and to improve immunity.
  

🔷Pharmacological management of angina pectoris

Medications are prescribed to manage events of angina and to relieve chest pain, also helps in managing angina in the long term. The selection of drug class is based on the type of angina. Following are the different drug classes used in treating angina: 

• Beta blockers: These agents reduce myocardial oxygen demand by reducing heart rate, contractility, and blood pressure. They reduce mortality. They act by competitively inhibiting the circulating catecholamine's action on cell membrane beta‐adrenergic receptors. They decrease mortality and morbidity followed by acute myocardial infarction. Many studies have recommended that these agents have to be given early in the absence of contraindications. 

• Nitrates: Nitrate therapy is the oldest treatment regimen in patients with angina pectoris. They are used to relief chest pain, decreases myocardial oxygen consumption by vasodilation (by reducing preload and left ventricular end-diastolic volume). They act by as veno dilators and arterial dilators, and can reduce myocardial oxygen demands while maintaining coronary artery flow. 

• Calcium channel blockers: These are important adjuvants in treating typical angina and are the drug of choice for angina that occurs due to coronary artery spasm. They are as effective as nitrates and beta blockers and may also be used in combination with these two drug classes. This drug class acts by relaxing the muscle cells of the heart and blood vessels. Calcium channel blockers are prescribed in cases where beta blockers and nitrates are not considered. 

• Antiplatelets: Antiplatelet agents decreases the risk of cardiovascular events in patients with stable or unstable angina. This therapy is an important and essential element in the treatment of angina pectoris. Monotherapy with antiplatelet is recommended in the absence of contraindications in all patients with diagnosed unstable angina whereas dual therapy with antiplatelet is recommended initially for all patients with stable angina. 

• Anticoagulants: They are used intravenously for acute treatment, and they reduce mortality by reducing reinfarction rates in combination with antiplatelet agents. The primary goal of anticoagulant therapy is to prevent the progression of thrombus thereby preventing myocardial infarction and death. 

• Statins: They act by preventing plague formation and slowing down coronary heart disease. They also relieve inflammation and spasm in blood vessels. The beneficial role of these drugs is driven by their lipid-lowering effect and is also due to their pleiotropic effects on the molecular pathways involved in inflammation and oxidative stress. 

• Morphine: It is an opioid analgesic, helps in relieving pain and relaxing muscles in blood vessels. These drug classes reduce blood pressure, slow heart rate, and relieve anxiety, making the patient feel better and may also decrease cardiac oxygen demand. But it also depresses respiration, that decrease oxygenation. These drug classes may not be used unless the patient is resistant to guideline‐based acute coronary syndrome treatment.
  

When angina is not managed by lifestyle modifications and with the use of medications, medical procedures are considered in treating angina. The following are the revascularization strategies performed: 

• Coronary artery bypass grafting (CABG): It is a high-risk surgical procedure in the setting of angina pectoris. This procedure is indicated in patients whose symptoms are refractory to medical therapy, hemodynamic instability, left main or triple vessel disease, or percutaneous coronary intervention not suitable or failed percutaneous coronary intervention.  In this procedure, the blocked portion of the coronary artery is bypassed with a section of a healthy blood vessel from the body. The healthy blood vessels may be pieces of a vein from the leg or an artery of the chest. The cardiologist may attach one end of the graft above the blockage and the other end below the blockage. Then blood bypasses the blockage through the new graft to reach the heart muscle and this is called coronary artery bypass surgery.

• Percutaneous coronary intervention (PCI): It is a non-surgical procedure that is used to treat the blockages in a coronary artery; it restores blood flow to the heart by opening narrowed or blocked areas of the coronary artery. It is indicated in coronary artery disease (CAD), chronic total occlusion, acute coronary syndromes (ACS), and angina. A small tube or a sheath is inserted into the blood vessel of the wrist or groin. Then a catheter is placed within the sheath and guided through it to the heart. X-ray images help the physician guide the catheter through blood vessels until it reaches the damaged area of the coronary artery. Then a physician injects a contrast liquid into the artery. This liquid enables certain tissues visible more in X-rays, allowing physicians to determine where the coronary artery is narrowed or blocked. 

✅ Angina pectoris prognosis 

The prognosis of progression of chronic stable angina to cardiac events varies among patients. The factors that affect angina prognosis include cardiovascular comorbidities as well as compliance with lifestyle changes and treatment plans.

Prognosis in the long term is also affected by left ventricular systolic function, and the degree and extent of exercise the patient can tolerate. Diabetes mellitus, previous history of myocardial infarction, hypertension, increasing age, and male sex are some of the risk factors for poor diagnosis.