Angina pectoris

Angina pectoris 

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Definition

Angina pectoris (commonly known as angina) is sensation of chest pain or discomfort due to coronary heart disease.  It occurs when the heart muscle doesn’t get as much blood as it needs. This usually happens because one or more of the heart’s arteries is narrowed or blocked which results in an imbalance between the heart’s oxygen demand and supply.  There are two main types: stable (also called effect angina) and unstable angina. The most commonly used medication to treat angina is nitroglycerin.

Epidemiology and burden of Angina

  • The World Health Organization (WHO) estimates that 54 million people live with angina pectoris globally, of whom 16 million are from the WHO South-East Asia region (BMC Public Health. 2014 Feb 19;14:179)
  • As of 2010, angina due to ischemic heart disease affects approximately 112 million people (1.6% of the population) being slightly more common in men than women (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61729-2/abstract)
  • Between 10 to 30% of patients with coronary disease still suffer from symptoms of agina pectoris in contemporary clinical practice (Clin Cardiol. 2007 Feb;30(2 Suppl 1):I10-5.)
  • In the United States are higher among women than men (http://circ.ahajournals.org/content/117/12/1505)
  • Angina prevalence varied approximately 20-fold between countries, ranging from 0.73% to 14.4% in women and 0.76% to 15.1% in men (http://circ.ahajournals.org/content/117/12/1505)
  • According to the Framingham Heart Study, an estimated 500,000 new cases of stable angina occur each year in USA (http://www.hcplive.com/medical-news/angina_statistics)
  • People with an average age of 62 years, who have moderate to severe degrees have a 5-year mortality rate of approximately 8% (http://www.nejm.org/doi/pdf/10.1056/NEJMoa070829)

Treatment for Angina

  • Trimetazidine and other anti-anginal drugs was associated with a smaller weekly mean number of angina attacks (p<0.001) than treatment of other anti-anginal drugs for stable angina pectoris (Int J Cardiol. 2014 Dec 20;177(3):780-5).
  • Chances of angina attacks were significantly higher with immediate-release nifedipine compared to sustained-release/extended-release nifedipine (P=0.001), and the occurrence was more for nifedipine monotherapy than that for nifedipine combination therapy (P=0.03) (Hypertension. 1999 Jan;33(1):24-31)
  • There is very low evidence to support the use of acupuncture for improving angina symptoms (BMC Complement Altern Med. 2015; 15: 90)
  • SCS found to be equally efficacious and safe treatment option in the management of refractory angina patients similar to PMR, a potential alternative treatment (BMC Cardiovascular Disorders 2009 9:13)
  • Antiischemic agents, including beta-blockers, nitrates and calcium channel blockers, remain the mainstay in the prevention of angina (Curr Opin Cardiol. 2006 Sep;21(5):492-502)

Prevention of Angina

  • A 50% increase in selenium concentrations was associated with a 24% (7%, 38%) reduction in coronary heart disease risk (Am J Clin Nutr. 2006 Oct;84(4):762-73)
  • L-carnitine was found to be associated with a 40% reduction in the development of angina (RR, 0.60; 95% CI, 0.50-0.72; p<0.0001) (Mayo Clin Proc. 2013 Jun;88(6):544-51)
  • Long-term use of aspirin dosages greater than 75 to 81 mg/d or higher dosages, which may be commonly prescribed, do not better prevent events but are associated with increased risks of gastrointestinal bleeding (JAMA. 2007 May 9;297(18):2018-24)
  • Those people who drink ≥4 cups/day have a reduced risk of myocardial infarction compared to those who drank <1 cup/day (OR=0.68, 95% CI: 0.56-0.84) (Int J Cardiol. 2016 Jan 1;202:967-74)
  • Long-term administration of nitrates is beneficial for angina prophylaxis (Int J Cardiol. 2011 Jan 7;146(1):4-12)

Risk factors for Angina

  • Low education is a risk factor for undiagnosed angina (J Am Board Fam Med. 2012 Jul-Aug;25(4):416-21)
  • Angia pectoris was found to be related to elevated serum cholesterol, elevated systolic and diastolic blood pressure, increased relative body weight, smoking, diabetes mellitus, low physical activity during leisure time, dyspnea and mental stress (J Chronic Dis. 1987;40(3):265-75)
  • Snoring is a risk factor for hypertension and angina pectoris (Lancet. 1985 Apr 20;1(8434):893-6)
  • Pooled analysis of clinical studies indicated an increased risk of angina (pooled adjusted effect estimate 1.29, 95% confidence interval 1.17-1.43; p < 0.0001) in migraineurs compared to non-migraineurs (Eur J Neurol. 2015 Jun;22(6):1001-11)
  • 18 –year long study proved that South Asians had higher cumulative incidence of angina than Whites (J Public Health (Oxf). 2011 Sep;33(3):430-8)
  • In patients with angina, omega-3 fatty acids increases the risk of sudden cardiac death (SCD) (RR = 1.39; 95% CI: 1.01-1.92) (Ann Med. 2009;41(4):301-10)

Systematic reviews

  • Ginkgo Biloba extract may have beneficial effects on patients with angina pectoris..more
  • Meta-analysis of eligible RCTs provides evidence that Guanxinning injection (GXN) is effective in treating angina pectoris..more
  • Compared with western medications alone, sulfotanshinone sodium combined with western medications may provide more benefits for patients with unstable angina..more
  • Compared with conventional antianginal drugs alone, ligustrazine injection combined with antianginal drugs significantly increased the efficacy in symptom improvement..more

Treatment with Medicinal Herbs

  • FIVE-LEAVED CHASTE, HUANG JING (Vitex negundo) – Dose – 3-9 fruits in decoction; 15-30 g as powder 
  • FLANNELWEED, COUNTRY MALLOW (Sida cordifolia) – Dose – 1-3 g powder, 2-20 ml root tea
  • GINKO MAIDENHAIR TREE (Ginko biloba) – Dose – 4.5 g seed; 1-2 tbsp fresh leaf

Handbook of Medicinal Herbs (2006)

Herbals