Angina pectoris: The Types, Causes and Risk factors

Angina pectoris, also known as Angina, a symptoms of  Ischemic heart disease, is defined as a condition of chest pain caused by poor blood flow through the blood vessels due to obstruction or spasm of the coronary arteries resulting of lack of blood that lead to lack of oxygen supply and waste removal. 

Types of Angina pectoris
1. Stable angina res
Stable angina is the chest pain occurred after physical activity or stress and may last up to 10 minutes. the symptoms may improve or go away when stop or slow down the exercise.

2. Unstable angina 
Unstable angina is a type of angina with chest pain occurs even at rest, with Crescendo angina and/or new-onset angina(1)

Beside chest pain or discomfort, patients with angina may also experience heaviness, tightness, squeezing, burning, or choking sensation of the chest and pain in the back, neck area, jaw, or shoulders. These are results of the pain perceived at a location other than the chest depending to the spinal level that receives visceral sensation.

Causes and risk factors 
A. Causes
A.1. Stable angina
Physical exertion is the most common cause of stable angina as a result of severely narrowed arteries of that interfere with the blood flow to the heart.

A.2. Unstable angina
Unstable angina is a condition of blood clots causes of  partially or totally block of an artery as a result of rupture of an artery. If severe case, large blood clot can increase the risk of cardiovascular diseases,
Blood clots may form, partially dissolve, and later form again. Angina can occur each time a clot blocks an artery.

B. Risk factors
1. Cigarette smoking
Men who are smokers are at higher risk to develop angina. According to the study of Framingham Heart Study, posted by Harvard University, indicated that those less than 60 years of age at angina onset who were nonsmokers or quitters during follow-up had a definite prognostic advantage over similarly aged continuing smokers. These results could not be explained by differences in coronary risk factors prior to symptom onset or by changes in factors other than smoking during follow-up. The findings suggest that stopping the cigarette smoking habit can improve both short-term and long-term prognosis in the younger patient and angina pectoris(2).

2. Obesity
in the study to evaluate the effects of moderate weight loss, in overweight patients with angina, on plasma coagulation, fibrinolytic indicies and pain frequency, at the University of Glasgow, researchers found that after the 12-week dietary intervention period, mean body weight fell by 3.5 (s.d. 2.6) kg or 4.3% (P=0.0001), range -11.7 to +1.7 kg. Mean angina frequency fell by 1.8 (s.d. 3.6) from 3.2 to 1.4 episodes/week (P=0.009) and plasma cholesterol by 0.4 (s.d. 0.7) from 6.3 to 5.9 mmol/l (P=0.0001). HDL cholesterol and triglyceride were unchanged. Of the coagulation and fibrinolytic factors, factor VII activity and RCA were significantly reduced by 5 (s.d. 20), IU/dl (P=0.04) and 1.3 (s.d. 1.3) arbitrary units (P=0.014), respectively(3).

3. Diabetes 
In the study of nineteen diabetic and 25 nondiabetic patients with exertional angina were exercised on a treadmill to measure anginal perceptual threshold, researchers at the Newham General Hospital found that the diabetic group had a longer anginal perceptual threshold (138 +/- 64 seconds vs 34 +/- 51 seconds, p less than 0.001), which correlated positively with the somatic pain threshold (r = 0.5, p = 0.03); patients with more prolonged anginal perceptual thresholds tended to have higher somatic pain thresholds. In the diabetic group anginal perceptual (r = -0.3, p = NS) and somatic pain (r = -0.4, p = 0.05) thresholds tended to increase as the ratio of peak to minimal heart rate during the Valsalva maneuver fell below 1.21, but these variables were unrelated in the nondiabetic group(4).

4. High cholesterol 
According to the study of The Heart Center of Chonnam National University Hospita of 34 stable angina pectoris (SAP) patients showed that these patients had unstable plaques (UPs) (61.6±9.2 years, 24 males, 12.8%). The percentage of plaque area in the minimum luminal area in high low density lipoprotein-cholesterol (LDL-C)/high density lipoprotein-cholesterol (HDL-C) ratio patients was significantly higher than in low LDL-C/HDL-C ratio patients (72.7±9.5% vs. 69.9±9.3%, p=0.035). An LDL-C/HDL-C ratio >2.0 was an independent predictor for UPs in SAP patients (odds ratio 5.252, 95% confidence interval 1.132-24.372, p=0.034)(5).

5. High blood pressure
Hypertension is associated to increased risk of Angina pectoris. In the study ofManagement of patients with hypertension and angina pectoris, reserachers showed thatin managing the patient with hypertension and angina pectoris, it is important to determine whether the angina occurs in the setting of hypertensive hypertrophic disease alone or coexists with coronary arterial stenoses(6).

6. Sedentary lifestyle and Unhealthy diet
Lifestyle with no or irregular physical activity is associated with increased risk of Angina pectoris. Diet high in saturated and trans fat with less fruits and vegetables enhances the building up of blood cholesterol of that increase the risk of angina.

7. Family history of early heart disease
If you have a family history of early heart disease, you are at higher risk to develop angina pectoris as family history of premature coronary artery disease increase the risk of an imbalance between myocardial oxygen supply and demand that may result of angina.

8.  Coronary artery disease
Coronary artery disease can cause decreased blood flow to the coronary arteries from the heart as a result of narrowing of the small blood vessels that supply blood and oxygen to the heart.

9. Other heart diseases
Increased blood flow for patients with preexisting ischemic heart disease may reduced the risk of angina pertoris, according to the study of Efficacy of early invasive strategy of diagnostics and treatment of unstable angina at the background of preexisting ischemic heart disease, indicated that detection of indications for myocardial revascularization in patients with unstable angina including those at medium and low risk confirms necessity of application of early invasive strategy as conventional strategy ensuring timeliness of pathogenetic treatment. Absence of indications to myocardial revascularization in a limited group of patients gives an opportunity to clarify diagnosis, prescribe drug therapy and prevent unjustified hospitalizations(7)

10. Previous heart attack
Heart attack victims may experience a diversity of symptoms, including chest pain, heaviness, tightness, squeezing, burning, or choking sensation of the chest and pain in the back, neck area, jaw, or shoulders.

11.  Age and lower socioeconomic status
According to the study of Dr. Sekhri N, and the research team at the Barts and the London NHS Trust, here is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality(8).

12. Etc.

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