Angina pectoris

1. 0 Summary

Angina pectoris is the chest soreness which occurs when the heart and soul muscle could not received sufficient oxygenated blood. It is due to atherosclerosis which is the accumulation of the plaque at the coronary arteries that reduce the blood circulation to the center. Also, angina can leads an individual to heart disease such as coronary artery disease (CAD) or myocardial infections (MI). You will discover three varieties of angina which is the steady angina, unstable angina and variant angina and each of them are different of their signs or symptoms and treatments. Angina is diagnosed based on medical and genealogy, physical evaluation and test such as electrocardiogram (ECG) and coronary angiography. However, the patients' conditions will determine which methods need to be found in order to treat angina. Lastly, pharmacists play an important role besides doctors in dealing with the angina patients.

2. 0 Introduction

Angina pectoris is the medical term for chest pain or pain which is a common sign indicating the sign of heart and soul diseases, for example, cardiovascular system disease (CHD). The pain is induced by the insufficient of oxygen rich blood circulation to the center muscle which contributes to cardiac ischaemia. 1 Other than that, the cause is due to the build up of plaque called atherosclerosis which is the steady accumulation of fatty deposits and blocks several coronary arteries. As a result, the heart could not receive blood circulation as the coronary arteries become slim and stiff which minimizes the air source to the center. 1, 2

Besides that, angina can be grouped into four different types of categories such as stable angina, unstable angina and variant angina. A couple of distinctions in these four types of angina such as signs and symptoms therefore, they required particular treatments. For instance, stable angina is very common compare to variant angina. Other than that, doctors will do some physical exam or examines the patients' histories in order to diagnose whether they are in the chance to getting angina and they'll uses several methods like the exercise electrocardiogram (ECG), radioisotope check out and coronary angiography. After that, doctors will determine whether which treatment such as surgeryor medication is required to treat the patients. However, the patients cannot retrieve if indeed they didn't change their life-style and follow the doctors' tips.

2. 1 Indications and Symptoms

People who are identified as having angina pectoris will most likely express the sensation of tightness, pressure, squeezing and using in or about the breasts. The patients will come with an attack like the central torso pain which may disperse to the arms, neck, jaw, throat, back or higher abdomen. Also, they could also encounter shortness of breathing during physical exercise and follow by nausea, exhaustion, sweating, light-headedness, or weakness. However, not absolutely all chest discomfort is angina and sometimes it is caused by acid reflux (heart burn up) and lung infections or inflammation. Also, the signs or symptoms are vary depends on the sort of angina.

2. 2 When does indeed angina occur?

As it was stated, angina occurs when there can be an increase in the demand of oxygenated blood vessels to the center. More often than not, angina occurs when the patients are doing some vigorous exercises or activities such as climbing hill or carrying heavy groceries. At the same time, it will occurs when the patients experiencing psychological stress, digesting heavy metal with extreme heat range. The patients who had been diagnosed with variant angina could easily get angina attack even when they are relaxing.

2. 3 Causes of Angina

Coronary arteries will be the arteries which deliver oxygenate blood vessels to the heart muscle in order to keep the heart pumping. However, when the center could not receive sufficient amount of blood vessels, it can triggers angina attack. You will discover three important coronary arteries, kept anterior descending artery, kept circumflex artery and right coronary artery in heart which can causes angina when one of them are clogged. 7 This example reflects the indication of coronary arteries diseases (CAD) where the arteries are narrowed down due to the accumulation of plaque on the internal surfaces of the arteries. Also, the accumulation of plaque can cause the blood clot to form and block the arteries. 2, 7

Figure 2 shows the distinctions between a normal and healthy artery and a stop artery. Blood flows easily over the healthy arteries to the heart and the heart muscles can function normally without the interruption. However, this picture can't be seen in stop arteries. Coronary arteries diseases (CAD) occurs when one of the top arteries are narrowed by the plaque and angina could be believed as the arteries are having a hard time in providing oxygenated blood vessels to the heart. Also, blood maybe clot at the obstructed arteries and stop the blood vessels from moving to the center, when this happens, patients will face myocardial contamination (MI).

Besides that, atherosclerosis could be cause by higher level of cholesterol in blood vessels, smoking, over weight, diabetes mellitus and alcoholic beverages. Smoking increases atherosclerosis by maximized blood pressure and heart rate which cause the heart to demand for more myocardial air. It lowers the oxygen-carrying capacity and increases the recurrence of angina.

3. 0 Classification

3. 1 Stable Angina

Stable angina serves as a the rate of recurrence, duration or precipitating causes remain unchanged in the past 60 days which is the most frequent type of angina. 3 The strike last for about 10 minutes or less than that and can be relieved by relaxing or medication. Hence, patients who are identified as having stable angina will experience bout of chest discomfort that may spreads to the arms, back, or other areas that is usually predictable. The stimulus that will improve the myocardial air demand will induces secure angina by increasing the heart rate or blood pressure of the patients. 5 During physical exercise, sympathetic anxious system will be triggered and causes increase of the heart rate, blood pressure and contraction demanding more air. When the air demand is more than the heart and soul is able to supply, chest irritation maybe be sensed and this reflects the presents of MI. 4 Also, several arteries which can be narrowed down due to the buildup of plaque is one of the factors.

3. 2 Unpredictable Angina

Unstable angina is more dangerous than stable angina as it is an acute coronary syndrome and really should be cared for as emergency and become evaluated in a healthcare facility carefully. Also, it does not follow a design can happen without the exercise. 2, 3 Patients will experience an urgent pain or uncomfortableness which last longer and does not relieve by recovery or medication. This situation is causes by the narrowing of the coronary arteries by atherosclerosis. However, blood clots will be the major factors which contribute to the blockage of the arteries. In case the plaque ruptures, blood coagulum may form and stop the arteries as the blood coagulum can separate into larger clot which can cause heart attack. 2 Chest uncomfortableness can attack each and every time the blood is clot when the clots slightly dissolve that will later reform again. Besides that, patients will maintain the risk of myocardial ischemia, severe cardiac arrhythmias or even sudden dead. 6

3. 3 Variant Angina

Variant angina also known as Prinzmetal's angina is due to the coronary artery spasm which causes the artery wall surfaces to tighten up and thin. 2, 3, 6 As a result, it reduces the move of the bloodstream to the heart and thus, leading to chest pain. Usually, variant angina happens at night time or early time whenever a patient is at rest as a result of momentary reduced amount of the coronary air supply rather than the increase of myocardial air demand. 2 It may occur in a person with or without CAD as the spasms in at artery can be cause by exposure to the cold weather, emotional stress, medication which in turn causes vasoconstriction, smoking and the use of cocaine. 2

4. 0 Diagnose

If one is having the angina symptoms, she or he should seek advice from their doctor to be able to learn more about their complication. Doctors, who are in obligation will conducts a physical exam on the patients, enquire about the symptoms and get to know the risk factors and the family history of CAD or other cardiovascular disease. Besides that, doctors will conduct a few of the following test to be able to diagnose angina.

4. 1 Exercise Electrocardiogram (ECG)

ECG is one of the very most widely used exams which measure the rate and regularity of the heartbeat. 2, 5 It details the rhythm and electric activity of the heart and therefore, indicating the severe nature of coronary artery diseases. The patients will exercises on the fitness treadmill machine while doing the ECG test since angina occurs during activities. ECG will show an unnatural reading if the patients have narrowing coronary arteries. However, a lot of people with angina also have a standard ECG readings and therefore, exercise stress screening is completed.

4. 2 Coronary Angiography

It is a arteries or center chambers assessment using X-ray and it is tested during catheterization. A catheter (fine, hollow pipe) will be placed into an artery in the patient's forearm or groin and move forward it till it extends to the coronary artery. Next, a dye which can be recognized by X-ray will injected in to the coronary artery and several pictures will be obtained. These pictures are called angiograms which is helpful for the doctors to observe which arteries are narrowed or clogged. 6

4. 3 Radioisotope scan

It is also called radionuclide check out which emits gamma rays. A small amount of radioactive isotope will be injected into the vein while the patients exercise. Then, the gamma rays will be recognized by the gamma camera which will be placed near to the chest to be able to detect which parts of the center muscles are obstructed. 9

5. 0 Treatment

The primary cause for angina is insufficient oxygen source which cannot meet the demand of the heart. Therefore, the procedure for angina is to make certain that the heart will receives sufficient air by balancing the air demand and supply. There are few means of treatment such as medication, surgery and changing the patients' lifestyle.

5. 1 Medical treatment

5. 1. 1 Nitrates

Nitrates are the most popular used drugs to treat angina as it open up the blood vessels and widens the coronary arteries (vasodilation), which allow more blood to move to the heart muscles and decrease the work of the heart and soul. 5 It plays the same effects of the endogenous nitrous oxide which bring about the powerful vasodilating results. 1 Nitrates take action by dilating the coronary arteries and peripheral blood flow, increase the myocardial oxygen supply by maximized the coronary circulation and lower the left ventricular blood pressure. Besides that, it can improve exercise tolerance in order to prolong the angina occurring by avoiding coronary spasm and coronary arterial vasoconstriction induced by exercise. 1, 6 Usually, sublingual nitroglycerin (GTN) tablets or aerosol are used to avoid ischemia before any exercise as it could quickly absorbed in to the buccal mucosa to provide a relief within 3 minutes. 5 Besides that, long-term nitrates for regular oral administration such as isosorbide mononitrate are normal practice among the list of patients. Although nitrates are non-toxic and well tolerated, it can cause headache, flushing and postural dizziness. 5

5. 1. 2 Beta-blockers

Patients who are identified as having angina but not contraindications will need beta-blockers as the first-line remedy. 5 Beta-blockers work by reducing the speed and force of cardiac contraction, arterial blood circulation pressure, and myocardial air demand of the heart during activities and improve coronary perfusion during diastole. Other than that, there can be an increase in survival rate of patients with MI who are taking beta-blockers. However, patients who have the history of bronchial asthma should not be prescribed with beta-blockers as they have a tendency to increase coronary vasospasm anticipated to unopposed alpha-agonist activity. 3 There are a few of approved beta-blockers which can be water-soluble and are used to treat angina such as perpanolol, metaprolol, atenolol, nadolol and timolol. Being that they are water-soluble, it is not as likely they will enter into the brain and cause central adverse effects. Besides that, beta-blockers also cause aspect results such as bradycardia and hypotension, lethargy, exhaustion and impotence. 11

5. 1. 3 Calcium mineral Channel Blockers

Calcium channel blockers perform the same effects of nitrates as vasodilators and increase myocardial air balance on coronary move and blood circulation pressure. They relieve angina and prolong the exercise time to onset of angina. Calcium route blockers inhibit calcium ions from streaming into the skin cells through available calcium channel and mediate the contraction of cardiac muscles. There are two types of calcium channel blockers, dihydropyridines such as nifedipine, amlodipine and felodipine and non-dihydropyridines such as diltiazen and verapamil. They work on the peripheral vasodilation, coronary vasodilation and lower the pace and force of cardiac contraction. Alternatively, patients who suffer from heart failing should avoid varapamil and diltiazen as they cause negative inotrophic action. Other side effects of calcium route blockers are facial flushing, throbbing headache, postural dizziness, mind ankle oedema and constipation. 2

5. 1. 4 Antiplatelets

Platelets are essential in blood vessels clotting and are likely involved in the pathogenesis of atherosclerosis. Also, it can obstructs the coronary arteries and causes the heart muscles from getting sufficient oxygenated blood vessels. Therefore, antiplatelet drugs such as aspirin are utilization in reducing the risk of death or nonfatal MI for patients with unstable angina. They can decrease the platelet aggregation by irreversible inhibiting the platelet enzyme cyocooxygenase-1 which prevents thrombaxane A2 development. 11

5. 2 Surgery

Doctors will suggest the patients to undergo coronary angioplasty or coronary bypass surgery if they cannot relieved by any medication or it is life threatening.

5. 2. 1 Coronary Angioplasty

That is cure which opens blocked arteries and enhances blood circulation to the center muscle, reduce breasts pain and prevent heart attack. Prior to the doctors perform coronary angioplasty on the patients, they will do an angiogram and take an X-ray picture of the patients' arteries. A catheter with a terminal balloon is introduced into an artery at the patients' groin or arm. X-ray screening process directs the catheter until it extends to the blocked arteries and few pictures are used. Then, the balloon will be inflated to press the fatty tissues outward resistant to the artery wall membrane. A 'stent' which is a small stainless mesh pipe will be positioned at the recently opened arteries as it could endure the arteries and reduce the arteries from narrowed down. 2, 3 Number 3 shows the blocked artery before and following the surgery.

5. 2. 3 Coronary Bypass Surgery

It is the most common type of center surgery and it has treatments at least 240, 000 patients in United States each year. It diverts blood vessels around clogged arteries in the heart by attaching a vein from the knee or artery from the torso or another part of the body between the aorta and the clogged area. Because of this, it creates a fresh road for the blood vessels to move to the heart and the heart and soul muscle will receive the oxygenated blood. Ever more, the left internal mammary artery has been used as the grafting bloodstream vessel since it results in a much better long-term final result and less likely to narrow over enough time compare to veins. 3 Prior to the surgery, the patients will go through coronary angiography to locate the narrowed arteries, come with an electrocardiogram, blood test, urine test and upper body X-ray to supply the latest health information for the doctors in charged. During the process, the heart and soul of an individual will be arrested and the breastbone will be divided as the blood vessels is send by way of a heart-lung machine. Following the surgery, you will see scars kept on the patients and they may feel chest discomfort that may tone down over time. 10

5. 3 Lifestyle Changes

A patient will not recovers from angina if she or he didn't change his or her lifestyle after taking medication or surgery as it plays a significant role in their life. By changing their life-style, patients can avoid the indication of angina and enhance their heart health. For instance, patients should modify a healthy diet plan which is full of fruits and vegetables and quit smoking. Also, patients who are obese should make an effort to lose their weight until it reaches the BMI (Body Mass Index) level. Other than that, they need to exercise regularly as directed by the doctors.

However, the most important things are to avoid bringing on an bout of angina such as taking a break or leftovers when the angina occurs with exertion. Also, the patients need to avoid taking a huge amount of food at a time after much meals. Finally, patients need to learn how to distress when they facing challenges as it'll triggers the angina to attack.

6. 0 Clinical Situation

6. 1 Clinical Circumstance 1

Aspirin is an antiplatelet medicine which is to avoid the aggregation of platelets and thus, reduce the threat of atherosclerosis. 75mg of aspirin is prescribed to the old man is sufficient to avoid the thromboxane A2 creation which is the initial dose given for permanent treatment. 11 Since aspirin can be an acetylsalicylic acid, the old man should take the tablets in the morning after food in order to lessen the stomachache discomfort. Patients who are identified as having asthma, pregnancy, haemophilia, hypertension and other bleeding disorders should avoid taking aspirins.

Atenolol is a О1 blocker which snacks angina by inhibiting the sympathetic nervous system. It decreases the heartrate and blood pressure, reduces the intake of oxygen and so, minimizes the regularity of angina. 100mg of atenolol is preferred daily in the morning because the blood pressure is at least expensive level and thus, it can preserves the blood circulation pressure. 3 Atenolol should be preserves away from the light and heat and stored in a firmly sealed pot. Doctors should make clear to the patients about the medial side effects of the medication such as dizziness, exhaustion and intimate dysfunction. However, patients cannot stop the medication as quick withdrawal of atenolol could cause exacerbation of angina. 11

GTN (glyceryl trinitrate) spray can be an aerosol aerosol which is used to dilate and broaden the wall space of coronary arteries and improve the flow of blood to the center. 3 It really is a common & most effective drug to ease angina as it offers a rapid relief of angina. Therefore, the patients should carry the squirt with them at all time. It should be used prior to the patients interesting any activities like climbing stairs which might lead for an acute attack of angina. The medial side effects of GTN spray are throbbing frustration, flushing, nausea and dizziness. 11

6. 2 Clinical Scenario 2

In circumstance 2, the functions of aspirin are been referred to in scenario 1 but the dosage given to this lady is leaner than in scenario 1. The prescription was presented with based on the reduction in bodyweight, total body water and mass. It is important to give a maximum degree of absorption, distribution, metabolism and excretion of medication in elderly patients with fewer part effects.

Imdur, which contains isosorbite mononitrate is employed to prevent the starting point of angina. Nitrates are powerful vasodilators which minimizes the workload of the heart and soul which causes a decease in the myocardial air demand. In cases like this, Imdur is given rather than beta-blocker because beta-blocker will reduce a patient's heartrate and blood pressure which may lead to heart failure and therefore, it is not well suited for this woman with a brief history of congestive heart failing. Also, a medication dosage of 60mg Imdur is sufficient and should considered once each day because the length of time of its action can depend on 12 hours also to decrease the development of tolerance regarding anti-angina effect. 3, 11

Lastly, GTN tablets were prescribed instead of aerosol in order to provide relieve for angina. It gets the same effects as GTN aerosol which is given under the tongue and being consumed while the tablet dissolves when the pain grows. A dose is able to provide comfort within one minute. The side ramifications of GTN tablets will be the identical to the aerosol.

7. 0 Role of Pharmacist

Doctors play an essential role in healing the patients who are identified as having heart attack and other diseases. However, the procedure is not complete without pharmacists because they are the people, who are popular for their tasks in prescribing drugs for the patients. Also, pharmacists also teach the general public about angina by deliver the announcements to the patients, ensuring the patients understand about their condition and assisting them to fight angina. So, a powerful communication skill is necessary in order to council the patients on the medication without any mistakes.

There are some people who are not aware that they are suffering from angina due to the lack of knowledge about angina. Because of this, some of them will simply recommend themselves with painkiller or any drugs which can relief their chest pain without knowing about the dangerous with their condition. Thus, the pharmacists are sensible to deliver the info about angina to produce awareness in the general public. The info about the signs and symptoms can surely help the public to aware about their health and to go for a medical check-up and seek treatment.

Every patient will vary and therefore, it is important they are treated differently predicated on their condition, intimacy, age group and existing condition such as hypertension, congestive heart failing and diabetes. It is because different conditions need different kind of medications in order to avoid any complications. For example, a patient who had center failure and suffers from angina should not be approved with beta-blocker as beta-blocker will worsen the individual condition.

Besides that, pharmacists should advise the patients on when as well as how to take the medication, the medication dosage of medication and how to keep carefully the medication. That is crucial as a straightforward mistake may lead the patients to loss of life such as overdose. Also, the pharmacists will advise the patients on what things to avoid and how to take care of themselves so that they can faster get over angina. For example, the pharmacists will advise them that they ought to avoid any vigorous activities watching their diets.

Lastly, a pharmacist should keep his/her patients' conditions private and private as this is the trust which his/her patient experienced given them. Also, it can benefit the pharmacist to screen the condition of their patients and to ensure that they will advantage most on the medication prescribed with minimal side effects.

8. 0 Conclusion

As been detailed, angina is not really a disease but an indicator indicating heart disease. It required a long-term treatment to be able to prevent angina from recurrence and should be taken significantly. So, the role of pharmacist is very essential by aiding the patients in handling their life and educating them on angina in order to lead them to healthier life.

9. 0 References

1. Williams, H. & Stevens, M. (2002) Chronic steady angina. Pharm. J. . 269:363-365
2. National Heart and soul Lung and Blood Institute, Disease and Condition Index. Angina.
3. Khan, M. G. , Topol, E. J. , Saksena, S. & Goodwin, J. F. (1996) CARDIOVASCULAR DISEASE Diagnosis and Remedy, A Practical Strategy. William & Wilkins, Baltimore. Webpages 133-183.
4. Lily L. S. Pathophysiology of CARDIOVASCULAR DISEASE: A Collaborative Task of Medical College student & Faculty. 3rd Release (2203) Lippincott. William & Wilkins.
5. Timmis A. D. and Nathan A. W. (1997) Essential of Cardiology. 3rd Model.
6. American Heart Association, Fighting CARDIOVASCULAR DISEASE and Heart stroke. Angina.
7. eHealthMD, Angina Pectoris. http://www. ehealthmd. com Accessed 28 Aug 2007.
8. iVillage Total Health, Angina. http://heart. health. ivillage. com Accessed 29 Aug
9. Patient UK, Radionuclide (Isotope) Check. http://www. patient. co. uk
10. Texas Center Institute, Coronary Artery Bypass. http://texasheart. org
11. British Medical Association and Royal Pharmaceutical Culture of Great Britain. British Country wide Formulary 43, March 2002. 2. 4 Beta-adrenoceptor blocking drugs, 2. 6. 1 Nitrates, 2. 6. 2 Calcium-channel blockers and 2. 9 Antiplatelet drugs.