Anginal Symptoms:

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Anginal Symptoms New Ways to Look at an Old
Problem
Murray Low, Ed.D., FAACVPR, FACSM President
AACVPR 2008 - 2009 E-mail mlow_at_exrx.com
Director - Cardiac Rehabilitation
------------------------ Stamford Hospital,
Stamford, CT The Burke Rehabilitation Hospital,
White Plains, NY Sound Shore Medical Center of
Westchester, New Rochelle, NY Northern
Westchester Cardiac Rehabilitation, PLLC, Mt.
Kisco, NY
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Atherosclerosis
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Atherosclerosis is a process in which deposits of
fatty substances, cholesterol, cellular waste
products, calcium and other substances build up
in the inner lining of an artery. This buildup is
called plaque.
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Clogged Arteries Cause Myocardial Ischemia
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Critical Areas of Atherosclerosis
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How Do we Diagnose Atherosclerosis?
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Stress Test
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ECG Analysis
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Ischemic ECG Changes
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This Heart is Getting Enough Blood
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Darker Areas of This Heart Scan Indicate
Inadequate Blood Supply
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Visualizing Diffuse Coronary Artery DiseaseWith
IVUS (intravascular ultrasound)
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Angina Pectoris

• Nearly 10 million Americans with coronary artery
  disease (CAD) experience angina
• 400,000 new cases diagnosed each year
• Many patients have two or more episodes of angina
  per week
• 1 in 10 people over 65 have angina
• Diagnosing angina may be challenging since
  atypical presentation of angina are common

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Is This Angina ?
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ANGINA PECTORIS ("ANGINA") is a recurring pain or
discomfort in the chest that happens when some
part of the heart does not receive enough blood.
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Episodes of angina occur when the heart's need
for oxygen increases beyond the oxygen available
from the blood nourishing the heart.
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Facts Angina is a temporary insufficiency of
blood flow to heart muscle. Angina does not
indicate a heart attack, nor is there ensuing
heart muscle damage.
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Anginal discomfort is rarely caused by abrupt
closure of a coronary artery, but rather results
from a temporary mismatch between restricted
blood flow (ischemia) in a preexisting obstructed
coronary artery and an increased bodily demand
for the heart to pump more blood
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ischemia is a restriction in blood supply
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The imbalance between the heart muscles oxygen
supply and demand leads to ischemia
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• Physical exertion is the most common trigger for
  angina.
• Other triggers can be
• Emotional Stress
• Extreme Cold or Heat
• Heavy meals
• Alcohol
• Cigarette smoking

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The All-Important Medical History
Identifying Angina
By far, the most important test in the diagnosis
of coronary artery disease is a detailed
conversation between a patient and a doctor or
health care professional
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Typical Signs/Symptoms
Angina feels like a pressing or squeezing pain,
usually in the chest under the breast bone, but
sometimes radiating to the shoulders, arms, neck,
jaws, or back. Angina is usually precipitated by
exertion. It is usually relieved within a few
minutes by resting or by taking prescribed angina
medicine.
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Symptom Recognition

• Bodily Location (substernal, radiating, neck,
  arm, wrist)
• Quality (pressure, tightness, squeezing)
• Chronology (usually lt10 min)
• Quantity (severity 1-4)
• Setting (activity)
• Aggravating or Alleviating factors (anger)
• Associated symptoms(nausea,dizziness..)

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Stable Angina (typical)

• Reproducible
• Predictable
• Usually produced by exertion
• Transient
• Relieved by rest or nitroglycerine

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Angina Scale

• 1 perceptible but mild
• 2 moderate
• 3 moderately severe
• 4 severe

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What MAY Angina Feel Like ?
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• While angina most often occurs as a form of chest
  pain or discomfort, some people experience less
  well-known, atypical symptoms of angina. These
  include
• Uncomfortable pressure, squeezing, heaviness, or
  burning in the chest
• Pain or discomfort in the shoulder, arm, back,
  neck, or jaw
• Shortness of breath
• Feeling faint
• Tiredness
• Heartburn

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Are we seeing the entire picture ?
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• Pressure or pain in the chest triggered by
  exertion
• Excessive sudden fatigue
• Heart palpitations or rapid heartbeat.
• Pain in the upper abdomen (similar to heartburn).
• Pain or discomfort in the arms, neck, jaw, or
  teeth.
• Lightheadedness, dizziness, fainting
• Profuse sweating
• Nausea (particularly in women)
• Shortness of breath
• A sudden general feeling of illness

Is There a change ?
Angina in Women May Be Different
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Medical Diagnosis Treatment Is Not Like STAR
TREK
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Medicine is Complex !
It Does Not Always Follow Simple Formulas !!
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The Levine Sign
The Palm Sign
The Arm Sign
The Pointing Sign
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• Methods
• 202 patients admitted to hospital with chest pain
• Patients were interviewed observed for signs
• Each patient had measurements for peak Troponin
  level, stress test or angiogram

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Largest area of chest discomfort correlated with
a greater likelihood of cardiac ischemia
lt55 Predictive for Ischemic chest discomfort
The Levine Sign
The Palm Sign
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The Arm Sign
The Pointing Sign
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Bottom line

• The absence of anyone gesture does not appear to
  rule out a diagnosis of myocardial ischemia
• Gestures may not be adequately useful to rule in
  a diagnosis of myocardial ischemia or infarct

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Can Chest Pain Relief By NitroglycerinePredict
Active Coronary Artery Disease?Cardiology Review
Volume 22 No 4 April 2005

• Studied 459 patients who were admitted to the
  Emergency department with an initial diagnosis of
  chest pain
• Pain level was recorded on a scale of 1 to 10
  before after administration of Nitroglycerine
• Patient was classified as being
  nitroglycerine-responsive if they had a
  greater than 50 reduction in pain (subjective
  scale)

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• Results
• 181 patients(39) of 459 had chest pain relief
• In 141 patients (31), chest pain was caused by
  active coronary artery disease (CAD)
• Of the 141 active CAD patients, nitroglycerine
  provided relief in 49 (35)
• For 275 subjects whose chest pain was not due to
  CAD, nitroglycerine provided chest pain relief in
  113 patients (41)

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Conclusions

• Chest pain relief with nitroglycerine does not
  aid in diagnosis of patients with chest pain who
  present to an Emergency Department
• Study Limitations.
• Only one dose of NTG was given
• NTG may have a Placebo effect
• This was an Observational study

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Unstable Angina (Variant/Printzmetal)
When the pattern of angina changes (new onset)
if episodes become more frequent, last longer,
or occur without exercise, the risk of heart
attack in subsequent days or weeks is much
higher.
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Treating Angina

• Medications
• Angioplasty/Stents
• Surgical Interventions (CABG)
• External Counterpulsation (EECP)
• Managing Risk Factors
• Smoking
• High Blood Pressure
• Abnormal blood fats
• Obesity/nutrition
• Diabetes
• Stress
• Physical inactivity

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Medications
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Medications

• Nitrates (coronary vasodilators)
• Beta blockers (reduce heart rate)
• Calcium Antagonist (vasospastic angina)
• Ranolazine (anti-ischemic)

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How They Work
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Enhanced External Counterpulsation (EECP)
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Diastole
Systole
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Cuffs Inflate Sequentially While The Heart Is
at Rest (Diastole)
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Heart is Preparing To Contract (Systole)
Cuffs Deflate Rapidly
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Managing Risk factors (lifestyle interventions)
For too long weve ignored our most powerful
weapon when it should be our first line of
defense.
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Everyone is Looking For The Magic Silver Bullet !
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Exercise is Medicine The Power of Fitness
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MET
One MET represents an average persons resting
metabolism or oxygen uptake. 1 MET 3.5ml/O2/kg
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Exercise Capacity and Mortality Among Men
Referred For Exercise Testing

• Beginning in 1987, 6,213 consecutive men referred
  for symptom limited treadmill exercise testing
• Subjects classified into two groups
• 3,679 had an abnormal GXT or history of CVD
• 2,534 had a normal GXT and no history of CVD
• Average 6.2 year follow-up

Myers, J., et al N Engl J Med 2002346793-801
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Relative Risk of Death by Exercise Capacity
Normal Subjects Subjects with
Cardiovascular Disease
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gt8 METs
Exercise Capacity was an Independent Predictor of
Mortality in Men Women
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Exercise Capacity and the Risk of Death in
Women Circulation. 20031081554-1559
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Popping Pills Is Not Enough To Compensate For Bad
Habits
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Combined Intense Lifestyle and Pharmacologic
Lipid Treatment Further Reduce Coronary Events
and Myocardial Perfusion Abnormalities Compared
With Usual-Care Cholesterol-Lowering Drugs in
Coronary Artery Disease
Stefano Sdringola, MD, FACC, et al JACC Vol. 41,
No. 2, January 15, 200326372
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Combined Intense Lifestyle Pharmacologic Lipid
treatment.

• Subjects
• 409 patients with CAD blindly categorized to 3
  treatment groups
• Evaluation
• Event Rate PET Scans

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Treatment Groups

• POOR treatment without diet or lipid drugs
• II. MODERATE treatment on AHA diet and lipid
  lowering drugs or on strict low fat diet(lt10
  fat) without lipid drugs
• III. MAXIMAL treatment with regular exercise,
  low fat diet(lt10), and lipid active drugs

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5 Year Event Rate
30.6
Poor Treatment
20.3
Statins/Diet
StatinsDietExercise
6.6
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Improved Perfusion Indicating Regression
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• Conclusions
• Angina occurs in nearly 1 of 5 patients 1 year
  after Myocardial Infarction
• After Hospital discharge, patients with angina at
  1 year were less likely to participate in
  cardiac rehabilitation, more likely to smoke and
  more likely to have depressive symptoms

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• Methods
• 1,152 patients with diagnosed CAD (mean age 61)
  participated in an intensive 12 week lifestyle
  intervention program (M757, W395)
• 3 hours/week of aerobic exercise
• Strength training 2 x Week
• Encouraged to eat a very low-fat plant based
  diet
• (lt10 fat)
• Practice stress management 1 hour/day
• Attend Group Support 2 hours per week

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• Results
• 74 of Angina patients became angina free
• An additional 9 moved from limiting to mild
  angina
• Improvement in angina were significant regardless
  of gender and initial intensity
• Patients who became Angina free showed the
  greatest improvement in exercise capacity,
  depression health related quality of life

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Conclusions Observed improvements in angina
patients making intensive lifestyle changes could
drastically reduce their need for
revascularization procedures
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Exercise Goals

• Increase Anginal Threshold
• Attenuate Risk Factors Associated With Coronary
  Artery Disease

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Exercise Prescription

• Use prolonged warm-up / cool down 10 min.
• Set upper limit ExRx 10 beats/min below anginal
  or ischemic ECG threshold
• Consider Intermittent training
• Prophylactic nitroglycerine may be appropriate
  (obtain MD orders)
• Exercise 30 mins/day, most days of the week

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Perceived Exertion Scale
Exercise Benefit Zone
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Journal of Cardiopulmonary Rehabilitation
September/October 2002 - Volume 22 - Issue 5 -
pp 368-369 2002 AACVPR Annual Meeting AACVPR
Meeting Abstracts RELATIONSHIP BETWEEN THE TALK
TEST AND ISCHEMIC THRESHOLD
Studied 19 patients with ST segment changes
consistent with exertional myocardial ISCH during
incremental exercise. Compared responses during
exercise using the Talk Test POSITIVE I can
still speak comfortably EQUIVALENT I'm not
sure I can speak comfortably NEGATIVE I can't
speak comfortably Versus minute-by-minute ECG
responses, to define the first evidence of
ISCHEMIA
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• Conclusions
• During the POSITIVE stage of the Talk Test , all
  variables were significantly less than ISCHEMIA
• the Heart Rate at POSITIVE was approximately 10
  bpm below ISHCEMIA
• The responses during the EQUIVALENT stage of the
  Talk Test were very similar to those at ISCHEMIA
• We conclude that when patients are able to speak
  comfortably, they are unlikely to have exertional
  ISCHEMIA

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Bottom Line .
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Exercise Is Medicine !

• ? All-Cause Mortality
• ? Max VO2
• ? MVO2 _at_ Workload
• ? Cardiac Output
• ? A-VO2 difference
• ? Recovery HR
• ? Submaximal HR _at_ WkLd
• ? Resting Blood Pressure
• ? Blood Clotting
• ? Endothelial Function
• ? Plasminogen Activator
• ? Fibrinogen Levels
• ? C-Reactive Protein

• ? LDL
• ? Triglyceride
• ? HDL-C
• ? Body Weight
• ? Body Fat
• ? Insulin Sensitivity
• ? Type II Diabetes
• ? Depression
• ? Osteoporosis
• ? Colon Cancer
• ? Breast Cancer
• ? Disability
• ? Dementia

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