Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

Ivabradine

Ivabradine is a specific and selective inhibitor of the If ion channel, the principal determinant of the sinoatrial node pacemaker current. Ivabradine reduces the spontaneous ring rate of sinoatrial pacemaker cells and thus slows the heart rate through a mechanism that is not associated with negative inotropic effects. At this time, ivabradine has been approved in Europe for the treatment of chronic stable angina pectoris in adults in sinus rhythm who are unable to tolerate or have contraindications to beta-blocking agents or in patients inadequately controlled with an optimal dose of a beta blocker and whose heart rate is faster than 70 beats/min. Ivabradine has also been approved in Europe for the treatment of chronic heart failure in combination with standard therapy in patients with a heart rate of 75 beats/min or greater.

Ivabradine reduces the peak heart rate during exercise, increases the time to limiting angina when compared with placebo, and is equivalent to atenolol with respect to exercise performance and time to ischemia (ST-segment depression) in patients with stable angina undergoing exercise treadmill testing. Ivabradine has also been shown to reduce the heart rate without any effect on ventilator parameters in patients with obstructive pulmonary disease [108] and to be tolerated in patients with CAD and LV dysfunction [109]. In a randomized trial of 10,917 patients enrolled in the Morbidity–Mortality Evaluation of the If Inhibitor Ivabradine in Patients With Coronary Artery Disease and Left Ventricular Dysfunction (BEAUTIFUL) trial, ivabradine did not reduce the primary endpoint of cardiovascular death, hospitalization for MI, or hospitalization for heart failure. Fewer hospitalizations for MI were observed in the subgroup of patients with a baseline heart rate greater than 70 beats/min who were randomly assigned to ivabradine versus placebo and in patients with a history of limiting angina [110].

Angina Pectoris

Stable angina pectoris is routinely treated with a variety of anti-ischemic drugs in addition to invasive interventions for revascularization, such as balloon dilatation of a stenosis, or cardiac surgery. Nitroglycerin and other nitrates are used for the treatment of acute symptoms. β-Blockers are first choice for long-term treatment, unless contraindications preclude the use of these drugs. The reduction in heart rate is the major basis of the anti-ischemic action of β-blockers, thus reducing myocardial oxygen consumption. Calcium antagonists, long-acting nitrates, low-dose aspirin, and a statin are usually included in the treatment schedule.

Stable Angina Pectoris and Silent Ischemia

Stable angina pectoris is defined as episodes of chest pain precipitated by physiologic situations of increased oxygen demands to the heart. It occurs most commonly during or immediately after exercise. In patients with atherosclerosis, angina is caused by the narrowing of coronary arteries to the point where there is insufficient delivery of blood and oxygen to actively respiring myocardial tissue. The affected areas of the heart are said to be ischemic, i.e., they are in danger for permanent myocardial damage, but myocardial necrosis does not occur in this condition, therefore, most biomarkers in blood are present within the normal range. However, there may be release of cardiac troponin, providing the basis for risk stratification. The atherosclerotic plaques are stable, in that they have a thick fibrous cap and are not in any immediate risk to rupture (Fig. 1a). The chest pain is relieved by rest or by medications such as nitroglycerin, which functions to diminish the oxygen demands of the heart.

Patients with silent ischemia have episodes of reduced blood flow that can lead to both myocardial ischemia and cell necrosis. Unlike patients with stable angina and acute coronary syndromes, those with silent ischemia do not present with any symptoms or knowledge that an ischemic event has taken place. Biochemical markers might be increased in the blood of patients suffering an event. However, in the absence of symptoms, the patient would not know to present to a hospital for blood collection. The diagnosis is made on the basis of stress testing, whereby ischemic episodes are induced under controlled conditions and monitored by continuous electrocardiographic recordings (ECG ST-segment depression of >1 mm) or nuclear imaging techniques (reduced coronary artery blood flow).

Symptoms

Stable angina is the most frequent initial manifestation of ischemic heart disease in women whereas acute MI and sudden death are more common initial presentations in men.30,31 Women report more angina than men,31a in part due to higher somatic awareness in women.31b Whereas both men and women experience typical and atypical anginal symptoms, approximately half of men have typical symptoms versus one-third of women.31c In a recent large multi-center study of symptomatic men and women with suspected CAD, chest pain was the primary symptom in approximately three-fourths of both men and women, although more women characterized the pain as crushing, pressure, squeezing, or tightness.31d Patients with CMD may have both typical and atypical symptoms of angina. In addition to exercise-induced or exertional symptoms, they may report symptoms at rest and prolonged symptoms. Dyspnea with exertion is common, and should be considered an angina equivalent. Because routine cardiac stress testing is designed to detect obstructive CAD, CMD can be missed.31e Given the atypical symptoms and nondiagnostic testing results, these patients may be misdiagnosed as having a psychiatric or gastrointestinal cause of their symptoms. Endothelial dysfunction, smooth muscle dysfunction, impaired microvascular vasodilatory capacity, elevated resting vasomotor tone, and abnormal cardiac nociceptive abnormality contribute to various degrees in an individual patient.31f Given the high burden of cardiovascular risk factors and associated morbidity, it is reasonable to empirically treat for CMD if diagnostic testing for its detection is not available.31e

Persistent chest pain at 1 year after angiography in women with no obstructive CAD predicts cardiovascular events, with twice the rate of composite events [nonfatal MI, stroke, heart failure, and cardiovascular (CV) death] compared to those without persistent chest pain.32 It is estimated that approximately 50% of women who present for chest pain evaluation continue to have symptoms at 5 years.33 These patients present repeatedly to clinicians and emergency rooms seeking answers for their persistent symptoms and have considerable associated anxiety due to the absence of a clear diagnosis; they undergo repeated cardiac testing, contributing to high healthcare costs. In the WISE study of 883 women, those with no obstructive CAD had an average lifetime cost estimate of $767,288 (95% confidence interval [CI] $708,480–$826,097), with expenses increasing as the number of vessels with CAD increased (Fig. 25.2).33

Medical conditions such as depression and anxiety can also contribute to angina and need to be appropriately addressed and managed, as patients with persistent chest pain but no coronary obstruction have a higher prevalence of depression and anxiety and are more likely to need psychiatric medication.28 Along with esophageal dysmotility disorders, a panic disorder should also be considered in those with recurrent chest pain that is out of proportion to objective evidence of ischemia found on testing. In one study of symptomatic patients with angiographically normal coronary arteries, 34% were found to meet Diagnostic and Statistical Manual of Mental Disorders criteria for having a panic disorder.34 In a pilot study from Amsterdam of 20 patients with chest pain and no obstructive CAD on angiography who were screened with State Scale and Trait Scale of the State-Trait Anxiety Inventory, those with high anxiety had more ischemia on myocardial perfusion imaging compared to those with low anxiety.35 In 2014, Vaccarino et al. reported a sex difference in mental stress–related myocardial ischemia in patients with a history of MI. Mental stress–induced ischemia was more common in younger women (age ≤ 50 years) compared to age-matched men, and this sex difference was not evident in those older than age 50 years.36 Mental stress has been associated with coronary endothelial dysfunction,37–39 and younger women may be particularly susceptible to adverse cardiac effects of mental stress.

Stable angina

Patients with stable angina usually have angina with effort or exercise or during other conditions in which myocardial oxygen demand is increased. The quality of sensation is sometimes vague and may be described as a mild pressure-like discomfort or an uncomfortable numb sensation. Anginal ‘equivalents’ (i.e., symptoms of myocardial ischaemia other than angina) such as breathlessness, faintness, fatigue, and belching have also been reported (Gersh et al 1997). A classic feature of stable angina is the disappearance of pain after the use of nitroglycerine or the inhalation of amyl nitrite.

A. Stable Angina

If stable angina is not adequately relieved by the combination of a beta-blocker, a nitrate, and a calcium blocker and lifestyle is deemed unacceptable by the patient or the physician, coronary artery bypass surgery is usually recommended. The main aim of surgery is to relieve pain. The complete relief of pain is certainly most satisfying and this is achieved in 90% of patients, whereas drugs achieve this goal in less than 50%. Drugs lessen the frequency of angina by about 60% in approximately 60% of patients treated. Some patients are satisfied with medical therapy and surgery is not indicated. About 40% of patients with angina are not satisfactorily controlled with medical therapy; these patients are recommended to have coronary arteriography with a view to CABG.

Patients with mild anginal symptoms may have severe atheromatous obstruction of the coronary arteries. Stress testing and nuclear scans may risk-stratify these patients; those with positive tests at a workload that is low are usually submitted to coronary arteriography.

Patients with mild stable angina with compromised left ventricular function as indicated by an ejection fraction (EF) of less than 45% and patients with diabetes may obtain improvement in survival with a revascularization procedure. The revascularization procedure may be bypass surgery or PCI. In addition, beta-blockers are contraindicated in patients with asthma and they may require revascularization at an early stage.

ANGINA

•

Stable angina begins at the same heart rate and blood pressure and is relieved by rest or nitroglycerin.

Angina is relieved by nitroglycerin.

Angina pain is not palpable.

Angina is associated with diaphoresis, shortness of breath, and feelings of doom.

Angina often is associated with electrocardiographic changes of ST-segment depression.

CHEST WALL PAIN

•

Nitroglycerin generally has no effect on chest wall pain.

Chest wall pain can occur at any time and last for hours.

Chest wall pain often is accompanied by muscle soreness, joint soreness, or deep breaths and evoked by palpation.

Minimal additional symptoms are associated with chest wall pain.

No ST-segment depression is seen on the electrocardiogram.

29. Can a patient experience a heart attack without the usual symptoms?

Yes. Sometimes heart attacks are silent. The patient does not experience chest pain but may complain of shortness of breath, weakness, and fatigue or flu-like symptoms. Because diabetic patients may have autonomic neuropathy, they may have no symptoms at all.

30. What are the exercise recommendations for patients with heart failure (HF)?

In the past, physical activity was restricted for patients with HF. In the past 15 years, however, research studies have shown that exercise can improve exercise tolerance and quality of life without adversely affecting ventricular function. Exercise guidelines for persons with HF are difficult to implement because the patient's condition frequently changes, but exercise can be done safely in selected patients. Patients should be assessed thoroughly before exercise, and vital signs and symptoms should be monitored closely during exercise. A relative contraindication for exercise is uncompensated HF. Compensated HF is determined clinically (for noninvasively monitored patients) by the ability to speak comfortably with a respiratory rate <30 breaths/min, less than moderate fatigue, crackles in less than one half of the lungs, and a resting heart rate <120 beats/min. Exercise should be terminated if the patient experiences marked dyspnea (inability to converse comfortably), extreme fatigue, abnormal hemodynamic effects, development of a third heart sound, increase in crackles, arrhythmias, or evidence of myocardial ischemia. Because persons with HF are generally quite deconditioned, a low level of effort may be sufficient to induce positive physiologic changes.

31. What types of exercise are recommended for patients with chronic primary or secondary pulmonary disease? Discuss the outcomes of such exercise.

Patients with pulmonary disease may benefit from breathing exercises, coughing techniques, cardiopulmonary endurance training, strength training, flexibility, respiratory muscle training, and relaxation exercises/techniques. Other components of rehabilitation should include airway clearance techniques, energy conservation/ventilatory strategy training, and patient education.

ADLs, Activities of daily living.

Adapted from Barr RN: Pulmonary rehabilitation. In Hillegass EA, Sadowsky HS, editors: Essentials of cardiopulmonary physical therapy, ed 2, Philadelphia, 2001, p 728, WB Saunders.

32. What is metabolic syndrome?

It is a combination of symptoms that helps to identify individuals who are at increased risk for a cardiovascular event and/or diabetes. The National Cholesterol Education Program's Adult Treatment Panel III requires that individuals have three out of the following five clinical findings for a positive diagnosis:

Increased abdominal circumference

Elevated levels of triglycerides

Low HDL levels

Elevated fasting blood glucose levels

High blood pressure

33. What type of physical activity or exercise is recommended for people with type 2 diabetes mellitus?

Within appropriate serum glucose levels, cardiovascular endurance exercise and resistance training exercise are recommended. Both can help control blood glucose levels by increased glucose utilization and improved insulin resistance, but these effects are lost after a few days of inactivity. Regular physical activity can lower blood pressure, improve lipid profile, and reduce emotional stress, which will reduce the overall risk of cardiovascular disease. Aerobic activity should be at the low to moderate intensity level and performed a minimum of 3 to 5 days/week with a goal of expending a minimum of 1000 kcal/week.

34. What exercise machines are recommended for home use in patients with osteoporosis?

The National Osteoporosis Foundation recommends exercise that promotes weight-bearing and impact through the lower extremities, such as brisk walking. Home exercise machines are recommended only as an adjunct to an existing exercise program. Treadmills offer a greater weight-bearing stimulus and impact than stair-climbers, and stair-climbers offer more impact than cross-country ski machines. Elliptical walkers and recumbent or stationary bicycles offer the least amount of weight-bearing and little or no impact through the lower extremities.

35. What are exercise concerns when prescribing exercise for the obese patient?

Many obese patients may have undiagnosed comorbidities (for example, heart disease or diabetes), orthopaedic limitations to weight-bearing exercises, heat intolerance, and low aerobic fitness level.

36. What are the most common causes of sports injuries in the older athlete?

Acute muscle injuries and overuse injuries in the lower extremities are the most frequent causes of sports injuries in the older adult. The knee is the most commonly injured body part in older athletes.

37. Is exercise recommended for patients with cancer?

In general, yes. Cancer and the adverse effects of treatment can cause generalized weakness and debilitation. Muscle strengthening and endurance exercise help to offset these effects. Because cancer and its treatment can affect response to exercise, all persons should be medically screened before participation in an exercise program. If the patient receives chemotherapy or radiation therapy or if the cancer involves the hematologic system, additional specific criteria should be assessed before treatment. Winningham's contraindications for aerobic exercise in patients receiving chemotherapy are platelet counts <50,000/ml, hemoglobin level <10 g/ml, white blood cell count <3000/ml, and absolute granulocyte count <500/μl. Immunosuppressed patients should be monitored closely during exercise for abnormal signs and symptoms of cardiopulmonary compromise. For patients unable to participate in aerobic exercises because of excessive fatigue, frequent short bouts of intermittent exercise may be indicated. Depending on the stage or severity of the disease, other therapeutic exercise treatments or interventions, such as functional training or energy conservation techniques, may be warranted.

38. Is exercise beneficial in older persons with cognitive impairment or dementia?

Yes; it can improve fitness, functional abilities, mental function, and behavior.

Western Medicine

a.

Stable angina:

Pain is relieved by rest and medicine

Pain lasts for a few minutes and is predictable

Low oxygen distribution

Narrow arteries blocked with plaque, especially coronary arteries

Difficulty with physical effort

Emotional upset

Smoking

Seasonal weather extremes

Unstable angina:

Pain is not relieved by rest or medicine

Arterial blockage by plaque and blood clots

Pain occurs during rest or physical effort, and is unpredictable

Variant angina:

Cornonary artery spasm

Occurs during sleep at night

Relieved by medicine

Microvascular:

Pain is longer in duration and is not relieved by medicine or rest

Pathophysiology

In typical stable angina, the pathology is usually atherosclerosis causing narrowing of coronary arteries. Physical exertion, emotional stress, exposure to cold, eating large meals, and smoking increases the oxygen demand of the heart. As the atherosclerotic coronary arteries cannot dilate sufficiently to supply enough oxygen to the working myocardium, the oxygen demand outpaces the supply and the myocardial oxygen supply-to-demand ratio falls below a critical level. In other words, cardiac work exceeds the needed oxygen supply and results in anginal pain. The myocardium becomes ischemic, which then causes chest pain. In variant angina, focal or diffuse coronary artery vasospasm episodically reduces coronary blood flow causing myocardial ischemic and chest pain. In patients with unstable angina, rupture of an atherosclerotic plaque, with subsequent platelet adhesion and aggregation, causes a coronary embolism that decreases coronary blood flow. The myocardium becomes ischemic, which then causes chest pain. To alleviate anginal pain, one or more major strategies are employed. These include decreasing cardiac workload and increasing coronary blood flow by vasodilation, decreasing cardiac work by decreasing the heart rate and force of contraction, and increasing or preserving coronary blood flow by reducing thrombi and emboli.