So angina pectoris, chest pain. It's an intermittent chest
It's caused by transient, reversible myocardial ischemia.
So this is not a heart attack. This is the warning shot
fired across the bow.
Okay. It is due to a variety of mediators that are
and the primary ones can be driving angina, that chest pain
is adenosine made by ischemic myocardium and it stimulates
autonomic nerve fibers
which sit in the pericardium and it causes the sensation of
And because of the way that the viscera don't have their own
they actually refer the pain out to certain dermatomes.
So, classically, the patient, as we'll see in a couple of
presents with left arm and shoulder pain, maybe left jaw
Okay. So stable angina, again, means we're pretty much to
where supply and demand are matched.
And at rest, I may have adequate supply to meet the demand.
Now if I increase my activity by running, I've increased
demand and my supply
may be inadequate, and I would develop, as a result of the
the increased heartrate, the increased demand on myocardial
cells to make ATP,
I may tip over into the point where I get angina.
Stable means reliably, every time I run around the block
once, I get chest pain.
Okay. That would be stable angina.
Alright. So stable angina presents typically because of the
to the C5, C6, C7 dermatomes of the left side.
And so you get a substernal sensation that often radiates
to the left arm, the left neck, the left jaw.
Some of the epigastric region or even to the back. That's
Patients don't always read the textbooks.
So they don't know what classic presentations they should
And some people's anginal equivalent, I've taken care of
where their anginal equivalent is not anything to do with
the left side.
They have right earlobe pain or they have right kind of
So you have to take a very good history.
And just because it's right-sided pain or it's, you know,
it's up here in the scalp,
you need to make sure that you are not missing a slightly
different anginal equivalent, okay?
You have classic presentation and you have atypical
So be careful. So with stable angina, again, supply and
demand is matched.
And if you have recurrent angina with relatively minimal
activity, that's kind of a pain.
Literally and figuratively and metaphorically, it's a pain.
So what you can do is if you know that you want to run
around the block,
you know it's going to cause chest pain.
It means, you know, there is a diminished -
there is an imbalance in terms of supply and demand,
you can treat that by increasing coronary perfusion.
You can provide better blood supply into the tissue by
and the typical one is that we do a sublingual
And sublingual nitroglycerin actually is converted into
and we already know that nitric oxide is a major smooth
muscle cell relaxant
which will increase the luminal diameter of the epicardial
So you can treat stable angina that way.
You probably ought to be thinking about maybe doing
something much more definitive than just taking
but patients are adequately treated that way.
With Prinzmetal angina, this is transient coronary spasms.
Sometimes, we haven't understood ideology in terms of
Other times, not so much. It's being shown here with a
It's much more common in women than in men.
And it will cause a vasospasm which can give you angina.
Actually, you can have such profound vasospasm that it can
actually in some cases,
if it's not released, if you don't restore normal tension,
normal flow to that vessel,
then you can actually get a myocardial infarct. How do we
Well, so they typically occur near your atherosclerotic
but can be in completely normal parts of the vessel.
And they respond very promptly to things like nitroglycerin
or calcium channel blockers.
So those are things that you can treat and sublingual
is a very effective treatment for that.
And then there is angina pectoris that is associated with
due to atherosclerotic plaques. So unstable angina can be
new onset chest pain.
It can be chest pain that increases with relatively lesser
amounts of excertion or it can be pain at rest.
Crescendo angina is kind of the middle of those categories.
It means that, "Gee, it takes less and less and less
activity for me to elicit my anginal symptoms."
So it's increasingly frequent pain, progressively, less
excertion. That's crescendo angina.
It's a form of unstable angina. What's going on with that?
Well, it's a combination of the plaque getting bigger and
or intermittent little areas of plaque rupture that are not
So you're not getting a myocardial infarct, but you are
getting partial occlusion,
and you're growing your atherosclerotic plaque by the
organization of that thrombus.
So that would be a very good explanation for crescendo
You can have beyond crescendo angina, now an acute plaque
and a complete occlusion with thrombus
and that, of course, is going to give rise to a myocardial