TREATING ANGINA: TYPES OF ANGINA

The first decision that has to be made is on the urgency of your case. Angina is divided into three main forms: stable, unstable, and variant (also called vasospastic or Prinzmetal’s angina).

In stable angina, there is usually a fixed stenosis of a particular segment of coronary artery that regularly leads to angina after the same amount of exercise. If you have it, you get to know just how much you can do before the pain starts. It can be precipitated by exercise, emotional excitement (remember John Hunter in chapter 1), or even by exposure to cold. Plunging the hands into cold water used to be a test for angina in the days before today’s more scientific tests. Stable angina is predictable, and tends to be well managed by the patient. It is not an indication for urgent treatment, unless the angiogram and scans show a very high immediate risk of complete blockage of an important artery.

Unstable angina is an emergency. It can develop after a period of stable angina. It occurs unpredictably, sometimes even at rest, as well as during exercise. It can deteriorate quickly, starting after less and less exercise that lasts over a few hours. It indicates that there is intermittent complete blockage of an artery that may soon become permanent, leading to a myocardial infarction (heart attack).

The probable cause of unstable angina is a thrombus (a clot) in the artery, which may be based on excessive platelet activity. People with this form of angina must be admitted to a coronary care unit and treated immediately with anticlotting (anticoagulant) drugs. They may even need emergency balloon angioplasty—a technique that is described later in this chapter.

Variant, vasospastic, or Prinzmetal’s angina can also be unpredictable, occurring without warning when the patient is resting. Paradoxically, it may disappear during exercise. Angiograms in Prinzmetal’s angina (it was named after the doctor who first described it) show no obstruction or stenoses, and very little evidence of atheroma. But when angiograms are done during an attack, they show that the coronary artery concerned is in spasm—a form of cramp of the vessel wall muscles that leads to transient narrowing. Prinzmetal’s angina responds very well to the calcium antagonist group of drugs to be described later. If you have it, you will not need surgery.

One unusual form of angina diagnosed at this stage is Syndrome X. It is called this because its cause is unknown, and it is also associated with clean coronary arteries. However, the EKG does show that the angina pain is real, with ischemic changes in areas of the heart on exercise. Patients with Syndrome X have other problems: they have hypertension and a higher than normal blood glucose level, though not enough for them to be diagnosed as having diabetes. If you are found to have Syndrome X, the aim of your treatment will be to bring your blood pressure and your blood glucose levels into their normal ranges. You will be advised on changes in your lifestyle and offered drug treatment for your hypertension, as well as the usual anti-angina treatment.

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