Anginal equivalent

Abstract: Angina pectoris has long been considered the cardinal symptom of myocardial ischemia. However, it is now known that angina pectoris may be a poor indicator for myocardial ischemia, particularly in patients with diabetes. Despite the recent advances in our understanding of the complex pathophysiology of coronary artery disease (CAD), the recognition of diabetic patients with asymptomatic and yet significant CAD remains difficult. CAD in diabetic patients poses diagnostic and therapeutic challenges for clinicians, especially when patients are asymptomatic during episodes of myocardial ischemia. In diabetic patients, cardiovascular disease remains the leading cause of death, and myocardial infarctions tend to be more extensive and have a poorer survival rate than in age-, weight-, and sex-matched individuals without diabetes. The medical cost associated with diabetes is staggering, amounting to about $100 billion annually, with vascular complications accounting for the majority of this expenditure. “Silent ischemia” refers to the presence of objective findings suggestive of myocardial ischemia that is not associated with angina or anginal equivalent symptoms. Such objective evidence includes exercise testing or ambulatory monitoring demonstrating electrocardiographic changes, nuclear imaging studies demonstrating myocardial perfusion defects, or regional wall motion abnormalities illustrated by echocardiography. Episodes of silent ischemia can occur with minimal or no physical activity and have been demonstrated in some individuals with stressors as mild as engaging in mental arithmetic. Diabetes, hypertension, previous myocardial infarction, surgical revascularization, and advanced age are all putative risk factors for silent ischemia, although many affected individuals do not have any apparent contributor. In the Framingham Study,1 which was based on 34 years of follow-up of more than 5,000 subjects, about one-fourth of the patients who experienced a heart attack had unrecognized events. Unrecognized infarctions consisted of silent myocardial infarctions and atypical myocardial infarctions. The latter are myocardial infarctions that are accompanied by some symptoms …

Abstract: The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.

Abstract: Introduction: Silent ischemia is an asymptomatic form of myocardial ischemia, not associated with angina or anginal equivalent symptoms, which can be demonstrated by changes in ECG, left ventricular function, myocardial perfusion, and metabolism. The aim of this study was to evaluate the prevalence of silent myocardial ischemia in a group of patients with asymptomatic carotid stenosis.

Abstract: Coronary artery disease (CAD) remains the most common cause of heart disease in the elderly, in whom it exhibits some unique features. It is more likely to be diffuse and severe and left main coronary artery stenosis and triple-vessel disease are more prevalent. Diagnosis is less dependent on the presence of chest pain since other symptoms may present as an anginal equivalent in such patients. The ECG of elderly patients often shows abnormalities that are not specific for myocardial ischaemia. In such patients, and in those who are unable to perform sufficient exercise to increase the heart rate to < 85%of predicted maximal heart rate for age and sex, radionuclide or pharmacological stress testing may be used. When the diagnosis of CAD remains questionable, coronary arteriography should be considered. Physical examination and basic laboratory screening should be used to identify conditions which exacerbate myocardial ischaemia and will, therefore, affect treatment. The initial approach to treatment should include risk factor modification and initiation of an anti-ischaemic pharmacological regimen. The usual anti-anginal medications are as efficacious in the elderly as in the young; however, attention must be paid to altered pharmacodynamics and pharmacokinetics. When symptoms are poorly controlled by medical therapy or when multivessel or left main coronary artery stenosis is identified, myocardial revascularization should be considered. In elderly patients with symptomatic angina or unstable angina symptoms, uncontrolled by medical therapy, percutaneous transluminal coronary angiography may be a reasonable alternative to surgical revascularization. ( Eur Heart J 1996; 17 (Suppl G ): 8–13)